Provider Demographics
NPI:1770849143
Name:FRED WESBERRY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:FRED WESBERRY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIMLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-362-9995
Mailing Address - Street 1:2900 S PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3237
Mailing Address - Country:US
Mailing Address - Phone:901-362-9995
Mailing Address - Fax:901-362-9989
Practice Address - Street 1:716 W BROOKHAVEN CIR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4504
Practice Address - Country:US
Practice Address - Phone:901-844-1590
Practice Address - Fax:901-844-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000000051261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical