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General NPI Number Information
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NPI Number | 1003822842
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Entity Type | Organization
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Legal Business Name | IMPLANT DENTISTRY OF THE MID SOUTH
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1000 BROOKFIELD RD SUITE 104
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City | MEMPHIS
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State | TN
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Zip | 38119-0802
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Country | US
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Telephone | 901-767-3259
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Fax | 901-683-4756
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Provider Business Mailing Address
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Address Line | 1000 BROOKFIELD RD SUITE 104
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City | MEMPHIS
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State | TN
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Zip | 38119-0802
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Country | US
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Telephone | 901-683-4756
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN WILLIAM PAYONK
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Credential | D.D.S.
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Telephone | 901-767-3259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS3315
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License Number State | TN
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