Provider Demographics
NPI:1528057254
Name:DENTISTRY AND FASTBRACES PC
Entity type:Organization
Organization Name:DENTISTRY AND FASTBRACES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S
Authorized Official - Middle Name:ADELE
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MPH
Authorized Official - Phone:615-851-4744
Mailing Address - Street 1:107 NEW BRICK CHURCH PIKE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1545
Mailing Address - Country:US
Mailing Address - Phone:615-851-4744
Mailing Address - Fax:
Practice Address - Street 1:107 NEW BRICK CHURCH PIKE
Practice Address - Street 2:SUITE C
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1545
Practice Address - Country:US
Practice Address - Phone:615-851-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-15
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4679261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0005870Medicaid