Provider Demographics
NPI:1598481764
Name:PEDIATRIC DENTAL CARE OF MEMPHIS, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CARE OF MEMPHIS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-288-8885
Mailing Address - Street 1:5286 COLE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2402
Mailing Address - Country:US
Mailing Address - Phone:901-288-8885
Mailing Address - Fax:901-375-9310
Practice Address - Street 1:717 S WHITE STATION RD STE 7
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4538
Practice Address - Country:US
Practice Address - Phone:901-363-8192
Practice Address - Fax:901-375-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty