Healthcare Provider Details

I. General information

NPI: 1497079032
Provider Name (Legal Business Name): EAST MEMPHIS DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5336 ESTATE OFFICE DR SUITE 1
MEMPHIS TN
38119-3623
US

IV. Provider business mailing address

5336 ESTATE OFFICE DR SUITE 1
MEMPHIS TN
38119-3623
US

V. Phone/Fax

Practice location:
  • Phone: 901-681-0408
  • Fax: 901-681-9753
Mailing address:
  • Phone: 901-681-0408
  • Fax: 901-681-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS7027
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS7770
License Number StateTN

VIII. Authorized Official

Name: DR. LANCE ASHLOCK
Title or Position: DENTIST
Credential: DDS
Phone: 901-681-0408