Healthcare Provider Details

I. General information

NPI: 1093965857
Provider Name (Legal Business Name): NICHOLAS LUKE EGBERT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7535 POPLAR AVE
MEMPHIS TN
38138-3812
US

IV. Provider business mailing address

7535 POPLAR AVE
MEMPHIS TN
38138-3812
US

V. Phone/Fax

Practice location:
  • Phone: 901-754-4200
  • Fax: 901-754-7511
Mailing address:
  • Phone: 901-754-4200
  • Fax: 901-754-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS0000008922
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: