Provider Demographics
NPI:1114214426
Name:AESTHETIC DENTISTRY OF COLLIERVILLE PLLC
Entity Type:Organization
Organization Name:AESTHETIC DENTISTRY OF COLLIERVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-853-8116
Mailing Address - Street 1:362 NEW BYHALIA RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3731
Mailing Address - Country:US
Mailing Address - Phone:901-853-8116
Mailing Address - Fax:901-853-0134
Practice Address - Street 1:362 NEW BYHALIA RD
Practice Address - Street 2:SUITE #3
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3731
Practice Address - Country:US
Practice Address - Phone:901-853-8116
Practice Address - Fax:901-853-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4231122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6588550001Medicare NSC