Organization
PEDIATRIC DENTISTRY OF LEBANON,PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LESLIE SUZANNE WALLACE DMD (DENTIST)
(615) 545-1812
Entity
Organization
Contact information
Practice address
103 PHYSICIANS WAY, STE 150, LEBANON, TN 37090-4132
(615) 545-1812
Mailing address
103 PHYSICIANS WAY, STE 150, LEBANON, TN 37090-4132
(615) 545-1812
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
8973
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1514855
—
TN
Enumeration date
09/01/2016
Last updated
09/01/2016
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