Provider Demographics
NPI:1588045454
Name:IMPERIAL DENTAL
Entity Type:Organization
Organization Name:IMPERIAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SPARKLE
Authorized Official - Middle Name:
Authorized Official - Last Name:EULLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-818-1990
Mailing Address - Street 1:5126 SUMMER AVE
Mailing Address - Street 2:101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4400
Mailing Address - Country:US
Mailing Address - Phone:901-818-1990
Mailing Address - Fax:901-818-1991
Practice Address - Street 1:5126 SUMMER AVE
Practice Address - Street 2:101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4400
Practice Address - Country:US
Practice Address - Phone:901-818-1990
Practice Address - Fax:901-818-1991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty