Provider Demographics
NPI:1215108923
Name:GERMANTOWN SMILE DESIGN PC
Entity type:Organization
Organization Name:GERMANTOWN SMILE DESIGN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:GAVIN
Authorized Official - Last Name:WALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-755-6440
Mailing Address - Street 1:7730 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1708
Mailing Address - Country:US
Mailing Address - Phone:601-755-6440
Mailing Address - Fax:901-755-6436
Practice Address - Street 1:7730 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1708
Practice Address - Country:US
Practice Address - Phone:601-755-6440
Practice Address - Fax:901-755-6436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000004635122300000X
TNDS00000004675122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4742Medicaid
TN9200300Medicaid
TN6472050001Medicare NSC