MEDICARE: NOTHSIDE DENTAL CENTER, PA

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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0149768	OTHER	TN	BLUE CROSS BLUE SHIELD TN

General Provider Information

NPI Number	:	1700851979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOTHSIDE DENTAL CENTER, PA

Provider Business Mailing Address
First Line	:	3067 N HIGHLAND AVE
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3411
Country	:	US
Telephone Number	:	731-668-7916
Fax Number	:	731-668-9544

Provider Business Practice Location Address
First Line	:	3067 N HIGHLAND AVE
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3411
Country	:	US
Telephone Number	:	731-668-7916
Fax Number	:	731-668-9544

Authorized Official
Title or Position	:	SECRETARY/TREASURER
Name	:	DR. FRANK H HAMPSON
Credential	:	D.D.S.
Telephone Number	:	731-668-7916

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	06/26/2008

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