Provider Demographics
NPI:1851860753
Name:WOLF RIVER DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:WOLF RIVER DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:S
Authorized Official - Last Name:BREAZEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-491-4859
Mailing Address - Street 1:61 PEYTON PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9702
Mailing Address - Country:US
Mailing Address - Phone:901-491-4859
Mailing Address - Fax:901-861-4031
Practice Address - Street 1:280 GERMAN OAK DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7220
Practice Address - Country:US
Practice Address - Phone:901-522-6640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty