| Organization Name: | AESTHETIC DENTISTRY OF COLLIERVILLE PLLC |
| NPI Number: | 1114214426 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ALAN O BLANTON (OWNER) |
| Mailing Address: | 362 New Byhalia Rd Suite #3 Collierville |
| State: | TN US |
| Postal Code: | 380173731 |
| Phone Number: | 9018538116 |
| Fax Number: | 9018530134 |
| NPI Enumeration Date: | 07/07/2011 |
| NPI Last Update Date: | 10/31/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BC3200X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Customized Equipment |
| Taxonomy Definition: | |