Provider Demographics
NPI:1215649694
Name:SPAULDING, KEITA (DMD)
Entity type:Individual
Prefix:
First Name:KEITA
Middle Name:
Last Name:SPAULDING
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 ASPEN GROVE DR APT 108
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2983
Mailing Address - Country:US
Mailing Address - Phone:615-476-4126
Mailing Address - Fax:
Practice Address - Street 1:212 INDIAN LAKE BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-6267
Practice Address - Country:US
Practice Address - Phone:615-431-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10960122300000X
TN124151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist