MEDICARE: DR. RYAN KEITH DAGEN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	9498	TN
2	122300000X	Dentist	9498	TN
3	1223G0001X	General Practice Dentistry	9498	TN

General Provider Information

NPI Number	:	1295098226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN KEITH DAGEN D.D.S.

Provider Business Mailing Address
First Line	:	5180 PARK AVE STE 310
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3531
Country	:	US
Telephone Number	:	901-685-1152
Fax Number	:

Provider Business Practice Location Address
First Line	:	5180 PARK AVE STE 310
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3531
Country	:	US
Telephone Number	:	901-685-1152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2012
Last Update Date	:	10/26/2024

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