Provider Demographics
NPI:1902338809
Name:MOUNT JULIET FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MOUNT JULIET FAMILY DENTISTRY
Other - Org Name:PARADISE FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERDOWSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-758-2085
Mailing Address - Street 1:66 E HILL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 E HILL DR
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8031
Practice Address - Country:US
Practice Address - Phone:615-758-2085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9932122300000X
1223G0001X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty