Healthcare Provider Details

I. General information

NPI: 1104367481
Provider Name (Legal Business Name): WHITEHAVEN DENTAL CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 E RAINES RD
MEMPHIS TN
38116-5816
US

IV. Provider business mailing address

1273 E RAINES ROAD
MEMPHIS TN
38116
US

V. Phone/Fax

Practice location:
  • Phone: 901-398-6435
  • Fax: 901-398-1987
Mailing address:
  • Phone: 901-398-6435
  • Fax: 901-398-1987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateTN

VIII. Authorized Official

Name: DR. RAGONVA SHANTE WALLS
Title or Position: DENTIST
Credential: DDS
Phone: 901-398-6435