NPIMap

Organization Active NPI

Pediatric Dentistry of Lebanon,PLLC

  • Pediatric Dentistry
  • Lebanon, TN
National Provider Identifier
1710434204
Registry record updated Sep 1, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
8973 Issued in TN
Legal business name
PEDIATRIC DENTISTRY OF LEBANON,PLLC
Practice address
103 Physicians Way
Ste 150
Lebanon, TN 37090-4132
Phone
(615) 545-1812
NPI assigned
Sep 1, 2016
Last updated
Sep 1, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 1, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Leslie Suzanne Wallace, DMDNPI 1629301833
Title
Dentist
Phone
(615) 545-1812

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Dentistry 1223P0221X 8973 TN Primary

Addresses

Primary practice location

103 Physicians Way
Ste 150
Lebanon, TN 37090-4132

Mailing address

103 Physicians Way
Ste 150
Lebanon, TN 37090-4132
Phone (615) 545-1812

Other identifiers 1

IdentifierTypeStateIssuer
1514855MedicaidTN

National Provider Directory

National Provider Directory

Locations

103 Physicians Way
Ste 150
Lebanon, TN 37090
Phone (615) 545-1812

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1472688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1472688000000",
    "number": "1710434204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 PHYSICIANS WAY",
            "address_2": "STE 150",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370904132",
            "telephone_number": "615-545-1812"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 PHYSICIANS WAY",
            "address_2": "STE 150",
            "city": "LEBANON",
            "state": "TN",
            "postal_code": "370904132",
            "telephone_number": "615-545-1812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC DENTISTRY OF LEBANON,PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-09-01",
        "last_updated": "2016-09-01",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_middle_name": "SUZANNE",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "615-545-1812",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "TN",
            "license": "8973",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1514855",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.