Provider Demographics
NPI:1003927310
Name:GERMANTOWN DENTAL GROUP
Entity Type:Organization
Organization Name:GERMANTOWN DENTAL GROUP
Other - Org Name:WHITTEMORE-GRUEN, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-754-0540
Mailing Address - Street 1:2165 WEST ST
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-754-0540
Mailing Address - Fax:901-754-0621
Practice Address - Street 1:2165 WEST ST
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-754-0540
Practice Address - Fax:901-754-0621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS2834261QD0000X
TNDS7364261QD0000X
TNDS7426261QD0000X
TNDS3429261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental