Provider Demographics
NPI:1255760385
Name:TENNESSEE DENTAL PROFESSIONALS PC
Entity type:Organization
Organization Name:TENNESSEE DENTAL PROFESSIONALS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:370 COLONIAL ROAD
Mailing Address - Street 2:3
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-853-9800
Mailing Address - Fax:
Practice Address - Street 1:370 COLONIAL ROAD
Practice Address - Street 2:3
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-853-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DENTAL PROFESSIONALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-08
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty