Healthcare Provider Details

I. General information

NPI: 1558659516
Provider Name (Legal Business Name): MACK ENDODONTICS DDS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 PARK AVE STE 300
MEMPHIS TN
38119-3531
US

IV. Provider business mailing address

5180 PARK AVE STE 300
MEMPHIS TN
38119-3531
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-2221
  • Fax: 901-683-2882
Mailing address:
  • Phone: 901-683-2221
  • Fax: 901-683-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7948
License Number StateTN

VIII. Authorized Official

Name: EDWARD M MACK
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 901-683-2221