MEDICARE: SANGO SMILES PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	8466	TN

General Provider Information

NPI Number	:	1538679097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANGO SMILES PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	7520 LORDS CHAPEL DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37211-7040
Country	:	US
Telephone Number	:	615-557-4442
Fax Number	:

Provider Business Practice Location Address
First Line	:	2622 MADISON ST STE G
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-6555
Country	:	US
Telephone Number	:	931-919-4898
Fax Number	:	931-919-4892

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CRYSTAL RUCKER
Credential	:	DMD
Telephone Number	:	615-557-4442

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	10/10/2017

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