Provider Demographics
NPI:1629262399
Name:BRINK & WHITE PEDIATRIC DENTAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:BRINK & WHITE PEDIATRIC DENTAL ASSOCIATES, PLLC
Other - Org Name:JOSHUA A BRINK, DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-382-0280
Mailing Address - Street 1:6565 STAGE ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-0280
Mailing Address - Country:US
Mailing Address - Phone:901-382-0280
Mailing Address - Fax:901-382-4148
Practice Address - Street 1:6565 STAGE ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-0280
Practice Address - Country:US
Practice Address - Phone:901-382-0280
Practice Address - Fax:901-382-4148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9177551Medicaid