Healthcare Provider Details

I. General information

NPI: 1295098226
Provider Name (Legal Business Name): RYAN KEITH DAGEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 10/26/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 PARK AVE STE 310
MEMPHIS TN
38119-3531
US

IV. Provider business mailing address

5180 PARK AVE STE 310
MEMPHIS TN
38119-3531
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-1152
  • Fax:
Mailing address:
  • Phone: 901-685-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9498
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9498
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9498
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: