Healthcare Provider Details

I. General information

NPI: 1376957357
Provider Name (Legal Business Name): BRETT MICHAEL DAGEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 12/19/2020
Certification Date: 12/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2093 PEABODY AVE
MEMPHIS TN
38104-4255
US

IV. Provider business mailing address

2093 PEABODY AVE
MEMPHIS TN
38104-4255
US

V. Phone/Fax

Practice location:
  • Phone: 901-359-5343
  • Fax:
Mailing address:
  • Phone: 901-359-5343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10328
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: