Provider Demographics
NPI:1447352372
Name:PROVIDENCE DENTAL CARE, INC.
Entity type:Organization
Organization Name:PROVIDENCE DENTAL CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LAFEVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-758-6800
Mailing Address - Street 1:684 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3323
Mailing Address - Country:US
Mailing Address - Phone:615-758-6800
Mailing Address - Fax:615-758-8419
Practice Address - Street 1:684 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3323
Practice Address - Country:US
Practice Address - Phone:615-758-6800
Practice Address - Fax:615-758-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000004058261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental