Provider Demographics
NPI:1124037379
Name:DECOLIBUS, KATHERINE ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ANNE
Last Name:DECOLIBUS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-3618
Mailing Address - Country:US
Mailing Address - Phone:901-680-0377
Mailing Address - Fax:
Practice Address - Street 1:10825 OLD HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-3599
Practice Address - Country:US
Practice Address - Phone:731-658-5291
Practice Address - Fax:731-658-6536
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN73891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN16170Medicaid