Healthcare Provider Details

I. General information

NPI: 1144433210
Provider Name (Legal Business Name): MARK RANDALL PATTERS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 UNION AVE UNIV. OF TENNESSEE, COLLEGE OF DENTISTRY
MEMPHIS TN
38163-0001
US

IV. Provider business mailing address

875 UNION AVE UNIV. OF TENNESSEE, COLLEGE OF DENTISTRY
MEMPHIS TN
38163-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-7686
  • Fax: 901-448-1625
Mailing address:
  • Phone: 901-448-7686
  • Fax: 901-448-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS0000005108
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: