Provider Demographics
NPI:1588055438
Name:HERITAGE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:HERITAGE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:865-986-5310
Mailing Address - Street 1:11121 KINGSTON PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:FARRAGUT
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2890
Mailing Address - Country:US
Mailing Address - Phone:865-986-5310
Mailing Address - Fax:
Practice Address - Street 1:11121 KINGSTON PIKE STE C
Practice Address - Street 2:
Practice Address - City:FARRAGUT
Practice Address - State:TN
Practice Address - Zip Code:37934-2890
Practice Address - Country:US
Practice Address - Phone:865-986-5310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS8701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty