Provider Demographics
NPI:1891043204
Name:DENTAL PRACTICE GROUP OF TENNESSEE
Entity Type:Organization
Organization Name:DENTAL PRACTICE GROUP OF TENNESSEE
Other - Org Name:BROOKHAVEN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHIAPARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-800-8040
Mailing Address - Street 1:136 4TH ST N STE 201
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3889
Mailing Address - Country:US
Mailing Address - Phone:727-800-8026
Mailing Address - Fax:727-304-3164
Practice Address - Street 1:775 E BROOKHAVEN CIR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4501
Practice Address - Country:US
Practice Address - Phone:901-682-3100
Practice Address - Fax:901-682-9848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PRACTICE GROUP OF TENNESSEE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ011942Medicaid
KY7100178860Medicaid