Provider Demographics
NPI:1346381977
Name:AMERICAN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:AMERICAN FAMILY DENTISTRY
Other - Org Name:COLLIERVILLE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-861-7098
Mailing Address - Street 1:2130 W POPLAR AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0615
Mailing Address - Country:US
Mailing Address - Phone:901-861-7007
Mailing Address - Fax:901-861-7066
Practice Address - Street 1:2130 W POPLAR AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0615
Practice Address - Country:US
Practice Address - Phone:901-861-7007
Practice Address - Fax:901-861-7066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERICAN DENTAL PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1700905080OtherGENERAL DENTIST