Provider Demographics
NPI:1588671770
Name:RALEIGH DENTAL GROUP
Entity Type:Organization
Organization Name:RALEIGH DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:A.
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-372-1221
Mailing Address - Street 1:4283 RALEIGH MILLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2207
Mailing Address - Country:US
Mailing Address - Phone:901-372-1221
Mailing Address - Fax:901-372-1251
Practice Address - Street 1:4283 RALEIGH MILLINGTON RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2207
Practice Address - Country:US
Practice Address - Phone:901-372-1221
Practice Address - Fax:901-372-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherGENERAL DENTIST