Provider Demographics
NPI:1841822301
Name:TREASURE ISLAND PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:TREASURE ISLAND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-698-0200
Mailing Address - Street 1:4119 SCOTT HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CULLEOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38451-3108
Mailing Address - Country:US
Mailing Address - Phone:931-444-5437
Mailing Address - Fax:
Practice Address - Street 1:1900 MEDICAL CENTER PARKWAY
Practice Address - Street 2:110
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:931-444-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ001715Medicaid