1215108923 NPI number — GERMANTOWN SMILE DESIGN PC

Table of content: (NPI 1215108923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215108923 NPI number — GERMANTOWN SMILE DESIGN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERMANTOWN SMILE DESIGN PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PICKWICK FAMILY DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215108923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7730 WOLF RIVER BLVD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38138-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-755-6440
Provider Business Mailing Address Fax Number:
901-755-6436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7730 WOLF RIVER BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-755-6440
Provider Business Practice Location Address Fax Number:
901-755-6436
Provider Enumeration Date:
03/20/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALLEY
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
GAVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-755-6440

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS0000004635 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: DS00000004675 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4742 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9200300 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".