Healthcare Provider Details

I. General information

NPI: 1053495697
Provider Name (Legal Business Name): NEW IMAGE FAMILY DENTISTRY R
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 RIVERDALE RD
MEMPHIS TN
38115-5322
US

IV. Provider business mailing address

3719 RIVERDALE RD
MEMPHIS TN
38115-5322
US

V. Phone/Fax

Practice location:
  • Phone: 901-365-2000
  • Fax: 901-365-2626
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberDS0000006961
License Number StateTN

VIII. Authorized Official

Name: DIRENDIA SHACKELFORD
Title or Position: MANAGED CARE SPECIALIST
Credential:
Phone: 800-654-0889