Provider Demographics
NPI:1043395023
Name:HENRY POLK DENTAL GROUP, DPC
Entity Type:Organization
Organization Name:HENRY POLK DENTAL GROUP, DPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-755-0001
Mailing Address - Street 1:8110 CORDOVA RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0520
Mailing Address - Country:US
Mailing Address - Phone:901-755-0001
Mailing Address - Fax:901-755-9679
Practice Address - Street 1:8110 CORDOVA RD
Practice Address - Street 2:SUITE 125
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0520
Practice Address - Country:US
Practice Address - Phone:901-755-0001
Practice Address - Fax:901-755-9679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty