Provider Demographics
NPI:1609400431
Name:PEDIATRIC DENTISTRY OF MEMPHIS PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF MEMPHIS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-598-8500
Mailing Address - Street 1:1594 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2124
Mailing Address - Country:US
Mailing Address - Phone:901-598-8500
Mailing Address - Fax:
Practice Address - Street 1:717 S WHITE STATION RD STE D
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:901-598-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029348Medicaid