Provider Demographics
NPI:1447848346
Name:ROCK DENTAL TENNESSEE PLLC
Entity type:Organization
Organization Name:ROCK DENTAL TENNESSEE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANEQUE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PHILMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-462-2062
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-3450
Mailing Address - Country:US
Mailing Address - Phone:501-781-2777
Mailing Address - Fax:501-781-2778
Practice Address - Street 1:6551 STAGE OAKS DR STE 2
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3895
Practice Address - Country:US
Practice Address - Phone:901-386-5800
Practice Address - Fax:501-781-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty