MEDICARE: DR. DERRICK D. PAYNE DDS

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	DS7858	TN

General Provider Information

NPI Number	:	1144211947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DERRICK D. PAYNE DDS

Provider Business Mailing Address
First Line	:	4466 ELVIS PRESLEY BLVD
Second Line	:	241
City	:	MEMPHIS
State	:	TN
Zip	:	38116-7180
Country	:	US
Telephone Number	:	901-396-7097
Fax Number	:	901-396-8214

Provider Business Practice Location Address
First Line	:	4466 ELVIS PRESLEY BLVD
Second Line	:	241
City	:	MEMPHIS
State	:	TN
Zip	:	38116-7180
Country	:	US
Telephone Number	:	901-396-7097
Fax Number	:	901-396-8214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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