Provider Demographics
NPI:1043388713
Name:CLARKSVILLE DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:CLARKSVILLE DENTAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-572-9175
Mailing Address - Street 1:1301 PEACHERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4610
Mailing Address - Country:US
Mailing Address - Phone:931-572-9152
Mailing Address - Fax:931-572-9155
Practice Address - Street 1:1301 PEACHERS MILL RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4610
Practice Address - Country:US
Practice Address - Phone:931-572-9152
Practice Address - Fax:931-572-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34171223G0001X
TN68501223G0001X
TN15421223G0001X
TN83011223G0001X
TN85801223G0001X
TN82751223G0001X
TN85961223G0001X
TN82901223G0001X
TN83171223G0001X
TN82591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN167716OtherTENNCARE-DORAL
TN1833308OtherUNITED CONCORDIA