Provider Demographics
NPI:1912556895
Name:UNIVERSITY OF TENNESSEE
Entity Type:Organization
Organization Name:UNIVERSITY OF TENNESSEE
Other - Org Name:PEDIATRIC DENTAL CLINIC AT LEBONHEUR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE CHANCELLOR/ CHIEF FINANCIA
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERRARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-448-5523
Mailing Address - Street 1:875 UNION AVE.
Mailing Address - Street 2:ROOM E201
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103
Mailing Address - Country:US
Mailing Address - Phone:901-448-6224
Mailing Address - Fax:901-448-2853
Practice Address - Street 1:848 ADAMS AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2816
Practice Address - Country:US
Practice Address - Phone:901-448-5437
Practice Address - Fax:901-448-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-04
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty