Provider Demographics
NPI:1497140008
Name:TENNESSEE DENTAL PROFESSIONALS PC
Entity Type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS PC
Other - Org Name:QUAIL HOLLOW FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:6425 N QUAIL HOLLOW RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6425 N QUAIL HOLLOW RD STE 102
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1438
Practice Address - Country:US
Practice Address - Phone:217-540-5170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty