Provider Demographics
NPI:1699850735
Name:PROPHETE, ADELINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADELINE
Middle Name:
Last Name:PROPHETE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 RIDGE LAKE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9426
Mailing Address - Country:US
Mailing Address - Phone:901-685-1003
Mailing Address - Fax:901-328-1566
Practice Address - Street 1:780 RIDGE LAKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9426
Practice Address - Country:US
Practice Address - Phone:901-685-1003
Practice Address - Fax:901-531-8399
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000669Medicaid