Basic Information
| Provider Information | |||||||||
| NPI: | 1437504529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANTZLER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | SUSANNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAVARES | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | SUSANNA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1744 UMBRIA DRIVE | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159799915 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 639 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372034226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152273000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 10632 | TN | Y | Dental Providers | Dentist | General Practice |
No ID Information.