Provider Demographics
NPI:1679955165
Name:MID-CUMBERLAND ENDODONTICS
Entity type:Organization
Organization Name:MID-CUMBERLAND ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDSCAGS
Authorized Official - Phone:931-388-5627
Mailing Address - Street 1:1324 TROTWOOD AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4750
Mailing Address - Country:US
Mailing Address - Phone:931-388-5627
Mailing Address - Fax:931-381-6797
Practice Address - Street 1:1324 TROTWOOD AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4750
Practice Address - Country:US
Practice Address - Phone:931-388-5627
Practice Address - Fax:931-381-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3913-1701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty