MEDICARE: MEMPHIS DENTAL STUDIO PLLC

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	:	1306706619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMPHIS DENTAL STUDIO PLLC

Provider Business Mailing Address
First Line	:	1520 FAIRFIELD DR
Second Line	:
City	:	LEBANON
State	:	MO
Zip	:	65536-4320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9755 US HIGHWAY 64 STE 104
Second Line	:
City	:	ARLINGTON
State	:	TN
Zip	:	38002-8395
Country	:	US
Telephone Number	:	901-902-5335
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HANEEN MATALGAH
Credential	:
Telephone Number	:	662-304-7605

Provider Enumeration Date	:	11/18/2025
Last Update Date	:	12/03/2025

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