Active NPI
Katherine Anne Decolibus, DDS
- General Practice Dentistry
- Bolivar, TN
National Provider Identifier
1124037379
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 7389
- Practice address
- 10825 Old Highway 64
Bolivar, TN 38008-3599 - Phone
- (731) 658-5291
- Fax
- (731) 658-6536
- NPI assigned
- Aug 5, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 7389 | TN | Primary |
Addresses
Primary practice location
10825 Old Highway 64
Bolivar, TN 38008-3599
Mailing address
4132 Poplar Ave
Memphis, TN 38117-3618
Phone (901) 680-0377
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 16170 | Medicaid | TN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7389 | TN | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Katherine a. Decolibus, DDS PLLC | General Practice | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Practice Dentistry
- Memphis, TN
- NPI 1245403708
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154736000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1249516800000",
"number": "1124037379",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4132 POPLAR AVE",
"city": "MEMPHIS",
"state": "TN",
"postal_code": "381173618",
"telephone_number": "901-680-0377"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10825 OLD HIGHWAY 64",
"city": "BOLIVAR",
"state": "TN",
"postal_code": "380083599",
"telephone_number": "731-658-5291",
"fax_number": "731-658-6536"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DECOLIBUS",
"first_name": "KATHERINE",
"middle_name": "ANNE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-05",
"last_updated": "2009-08-06",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TN",
"license": "7389",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "16170",
"state": "TN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bolivar, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.