Provider Demographics
NPI:1124283932
Name:COOKEVILLE REGIONAL DENTAL INC
Entity type:Organization
Organization Name:COOKEVILLE REGIONAL DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, EFDA
Authorized Official - Phone:931-528-5105
Mailing Address - Street 1:327 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2420
Mailing Address - Country:US
Mailing Address - Phone:931-528-5105
Mailing Address - Fax:931-528-5118
Practice Address - Street 1:327 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2420
Practice Address - Country:US
Practice Address - Phone:931-528-5105
Practice Address - Fax:931-528-5118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1223P0221X, 1223S0112X, 1223X0400X, 122300000X
TN38421223P0221X
TN90251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty