Provider Demographics
NPI:1992717573
Name:IROQUOIS FAMILY DENTISTRY
Entity type:Organization
Organization Name:IROQUOIS FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-298-2040
Mailing Address - Street 1:5115 HARDING PIKE STE 101
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2721
Mailing Address - Country:US
Mailing Address - Phone:615-298-2040
Mailing Address - Fax:615-777-2041
Practice Address - Street 1:5115 HARDING PIKE STE 101
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-2721
Practice Address - Country:US
Practice Address - Phone:615-298-2040
Practice Address - Fax:615-777-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11260OtherDENTAL LICENSE
TN5014OtherDENTAL LICENSE
TN8993OtherDENTAL LICENSE
TN11000OtherDENTAL LICENSE