Healthcare Provider Details

I. General information

NPI: 1649249533
Provider Name (Legal Business Name): RUSSELL C PECK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N PAULINE ST
MEMPHIS TN
38104-1005
US

IV. Provider business mailing address

5346 WILDBROOK CV
MEMPHIS TN
38120-2759
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-734-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS4250
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: