=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609400431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTISTRY OF MEMPHIS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2020
-----------------------------------------------------
Last Update Date | 04/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 S WHITE STATION RD STE D
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38117-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-598-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1594 OLD MILL RD
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-598-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID CALVIN HARRIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 901-598-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------