1285395020 NPI number — AMERICAN FAMILY DENTISTRY OF MEMPHIS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285395020 NPI number — AMERICAN FAMILY DENTISTRY OF MEMPHIS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN FAMILY DENTISTRY OF MEMPHIS, 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:
Provider Other Organization Name Type Code:
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:
1285395020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 GOODMAN RD W STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-9485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-253-3013
Provider Business Mailing Address Fax Number:
662-253-3021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 GOODMAN RD W STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-253-3013
Provider Business Practice Location Address Fax Number:
662-253-3021
Provider Enumeration Date:
01/04/2022

Additional Information

Authorized Official

Authorized Official Last Name:
HAYES
Authorized Official First Name:
CELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
217-540-2100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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