Provider Demographics
NPI:1700619244
Name:CD TENNESSEE DENTAL, P.C.
Entity type:Organization
Organization Name:CD TENNESSEE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-808-4984
Mailing Address - Street 1:9825 KENWOOD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6252
Mailing Address - Country:US
Mailing Address - Phone:513-808-4984
Mailing Address - Fax:513-448-0511
Practice Address - Street 1:3050 BUSINESS PARK CIR STE 202
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3588
Practice Address - Country:US
Practice Address - Phone:615-859-3700
Practice Address - Fax:615-859-6222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty