Provider Demographics
NPI:1114907201
Name:SIDWELL, IRA LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:LEE
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 OLD HICKORY BLVD
Mailing Address - Street 2:STE. 205
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4239
Mailing Address - Country:US
Mailing Address - Phone:615-269-5223
Mailing Address - Fax:615-269-6384
Practice Address - Street 1:1195 OLD HICKORY BLVD
Practice Address - Street 2:STE. 205
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4239
Practice Address - Country:US
Practice Address - Phone:615-269-5223
Practice Address - Fax:615-269-6384
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS37671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice