MEDICARE: HENRY POLK DENTAL GROUP, DPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1043395023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENRY POLK DENTAL GROUP, DPC

Provider Business Mailing Address
First Line	:	8110 CORDOVA RD
Second Line	:	SUITE 125
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-755-0001
Fax Number	:	901-755-9679

Provider Business Practice Location Address
First Line	:	8110 CORDOVA RD
Second Line	:	SUITE 125
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-755-0001
Fax Number	:	901-755-9679

Authorized Official
Title or Position	:	FINANCIAL COORDINATOR
Name	:	MRS. REAGAN JOHNSON
Credential	:
Telephone Number	:	901-755-0001

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	08/22/2020

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