Provider Demographics
NPI:1265084743
Name:DOUGLAS, BREION
Entity type:Individual
Prefix:DR
First Name:BREION
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 ALIXS DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-3303
Mailing Address - Country:US
Mailing Address - Phone:901-490-4438
Mailing Address - Fax:
Practice Address - Street 1:2900 KIRBY RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8221
Practice Address - Country:US
Practice Address - Phone:901-755-7392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist