Provider Demographics
NPI:1154350874
Name:CHILDREN'S DENTAL CENTER OF WEST TENNESSEE
Entity type:Organization
Organization Name:CHILDREN'S DENTAL CENTER OF WEST TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-861-9668
Mailing Address - Street 1:2028 W POPLAR AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0618
Mailing Address - Country:US
Mailing Address - Phone:901-861-9668
Mailing Address - Fax:901-861-9582
Practice Address - Street 1:2028 W POPLAR AVE
Practice Address - Street 2:STE 110
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0618
Practice Address - Country:US
Practice Address - Phone:901-861-9668
Practice Address - Fax:901-861-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN77781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3206803Medicaid
TN4100868OtherBLUE CROSS/ BLUE SHIELD