Healthcare Provider Details

I. General information

NPI: 1023158185
Provider Name (Legal Business Name): PERIODONTAL ASSOCIATES OF MEMPHIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 POPLAR AVE
MEMPHIS TN
38119-4713
US

IV. Provider business mailing address

6268 POPLAR AVE
MEMPHIS TN
38119-4713
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-3770
  • Fax: 901-761-3775
Mailing address:
  • Phone: 901-761-3770
  • Fax: 901-761-3775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS7731
License Number StateTN

VIII. Authorized Official

Name: MS. BARBARA F PATTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 901-761-3770