=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144089327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOVE FAMILY DENTISTRY - RALEIGH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2024
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4283 RALEIGH MILLINGTON RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-587-0828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4283 RALEIGH MILLINGTON RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-587-0828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | PAOLA RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------