Basic Information
| Provider Information | |||||||||
| NPI: | 1386758241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRROW | ||||||||
| FirstName: | VERAN | ||||||||
| MiddleName: | ANTONITA | ||||||||
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| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 HART LN | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372431405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156507021 | ||||||||
| FaxNumber: | 6152626139 | ||||||||
| Practice Location | |||||||||
| Address1: | MID-CUMBERLAND REGIONAL HEALTH DEPT | ||||||||
| Address2: | 710 HART LANE | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156507021 | ||||||||
| FaxNumber: | 6152626139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS0000005248 | TN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3202696 | 05 | TN | MEDICAID |