Provider Demographics
NPI:1003822842
Name:IMPLANT DENTISTRY OF THE MID SOUTH
Entity Type:Organization
Organization Name:IMPLANT DENTISTRY OF THE MID SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PAYONK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-767-3259
Mailing Address - Street 1:1000 BROOKFIELD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0802
Mailing Address - Country:US
Mailing Address - Phone:901-683-4756
Mailing Address - Fax:
Practice Address - Street 1:1000 BROOKFIELD RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0802
Practice Address - Country:US
Practice Address - Phone:901-767-3259
Practice Address - Fax:901-683-4756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS33151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty