Healthcare Provider Details

I. General information

NPI: 1477651545
Provider Name (Legal Business Name): WALLACE WYMON DYKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 POPLAR AVE STE. 406
MEMPHIS TN
38117-7503
US

IV. Provider business mailing address

4515 POPLAR AVE STE. 406
MEMPHIS TN
38117-7503
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-9800
  • Fax:
Mailing address:
  • Phone: 901-683-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3243
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: