Healthcare Provider Details

I. General information

NPI: 1114214426
Provider Name (Legal Business Name): AESTHETIC DENTISTRY OF COLLIERVILLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 NEW BYHALIA RD SUITE #3
COLLIERVILLE TN
38017-3731
US

IV. Provider business mailing address

362 NEW BYHALIA RD SUITE #3
COLLIERVILLE TN
38017-3731
US

V. Phone/Fax

Practice location:
  • Phone: 901-853-8116
  • Fax: 901-853-0134
Mailing address:
  • Phone: 901-853-8116
  • Fax: 901-853-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4231
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN O BLANTON
Title or Position: OWNER
Credential: DDS
Phone: 901-853-8116