MEDICARE: MAX S. BREAZEAL, D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1346021177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAX S. BREAZEAL, D.D.S.

Provider Business Mailing Address
First Line	:	61 PEYTON PKWY STE 103
Second Line	:
City	:	COLLIERVILLE
State	:	TN
Zip	:	38017-9724
Country	:	US
Telephone Number	:	901-861-0031
Fax Number	:	901-861-4031

Provider Business Practice Location Address
First Line	:	61 PEYTON PKWY STE 103
Second Line	:
City	:	COLLIERVILLE
State	:	TN
Zip	:	38017-9724
Country	:	US
Telephone Number	:	901-861-0031
Fax Number	:	901-861-4031

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LISA G HENLEY
Credential	:
Telephone Number	:	901-861-0031

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	10/09/2023

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