MEDICARE: MONUMENT DENTAL ANESTHESIA 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	1223D0004X	Dental Anesthesiology	9030	TN

General Provider Information

NPI Number	:	1356891675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONUMENT DENTAL ANESTHESIA PLLC

Provider Business Mailing Address
First Line	:	120 S GROVE PARK RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-3104
Country	:	US
Telephone Number	:	901-491-0971
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 S GROVE PARK RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38117-3104
Country	:	US
Telephone Number	:	901-491-0971
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUSSELL D MORRELL
Credential	:	DMD, MDS
Telephone Number	:	901-491-0971

Provider Enumeration Date	:	10/11/2016
Last Update Date	:	02/01/2017

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