MEDICARE: STATE OF TENNESSEE

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	1223D0001X	Public Health Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	014540	OTHER	TN	DORAL DENTAL LOCATION ID

General Provider Information

NPI Number	:	1720125545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF TENNESSEE

Provider Business Mailing Address
First Line	:	710 HART LN
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37216-2627
Country	:	US
Telephone Number	:	615-650-7000
Fax Number	:	615-262-6139

Provider Business Practice Location Address
First Line	:	710 HART LN
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37216-2627
Country	:	US
Telephone Number	:	615-650-7000
Fax Number	:	615-262-6139

Authorized Official
Title or Position	:	REGIONAL DIRECTOR
Name	:	MRS. ANNETTE HALEY
Credential	:
Telephone Number	:	615-650-7000

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	08/28/2012

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Directions to “STATE OF TENNESSEE ” Practice Location

Language	Start Address	Practice Location

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