MEDICARE: DENTAL EXCELLENCE MEMPHIS 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	:	1639043987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL EXCELLENCE MEMPHIS PLLC

Provider Business Mailing Address
First Line	:	5180 PARK AVE STE 310
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3531
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5180 PARK AVE STE 310
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3531
Country	:	US
Telephone Number	:	901-685-1152
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, PAYER RELATIONS
Name	:	AMANDA LIGHTFOOT
Credential	:
Telephone Number	:	214-702-0708

Provider Enumeration Date	:	09/30/2025
Last Update Date	:	09/30/2025

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