Active NPI
Ethelyn Jean Pak
- Dentist
- Smyrna, TN
National Provider Identifier
1083168538
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 10295
- Practice address
- 440 Sam Ridley Pkwy W
Smyrna, TN 37167-2998 - Phone
- (615) 625-2955
- NPI assigned
- Aug 12, 2016
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 10295 | TN | Primary |
Addresses
Primary practice location
440 Sam Ridley Pkwy W
Smyrna, TN 37167-2998
Mailing address
1518 Red Oak Dr.
Brentwood, TN 37027
Phone (615) 483-0728
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161010002161 | TN | Order and Referring Only - Dentist | 1951699800 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1470960000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1471392000000",
"number": "1083168538",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1518 RED OAK DR.",
"city": "BRENTWOOD",
"state": "TN",
"postal_code": "37027",
"telephone_number": "615-483-0728"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "440 SAM RIDLEY PKWY W",
"city": "SMYRNA",
"state": "TN",
"postal_code": "371672998",
"telephone_number": "615-625-2955"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PAK",
"first_name": "ETHELYN",
"middle_name": "JEAN",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2016-08-12",
"last_updated": "2016-08-17",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "TN",
"license": "10295",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Smyrna, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.