Provider Demographics
NPI:1497908354
Name:ALL ABOUT KIDS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:ALL ABOUT KIDS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-759-0970
Mailing Address - Street 1:3285 HACKS CROSS RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8918
Mailing Address - Country:US
Mailing Address - Phone:901-759-0970
Mailing Address - Fax:
Practice Address - Street 1:3285 HACKS CROSS RD
Practice Address - Street 2:STE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8918
Practice Address - Country:US
Practice Address - Phone:901-759-0970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440932Medicaid