Provider Demographics
NPI:1144211947
Name:PAYNE, DERRICK D (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:D
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4466 ELVIS PRESLEY BLVD
Mailing Address - Street 2:241
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7180
Mailing Address - Country:US
Mailing Address - Phone:901-396-7097
Mailing Address - Fax:901-396-8214
Practice Address - Street 1:4466 ELVIS PRESLEY BLVD
Practice Address - Street 2:241
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7180
Practice Address - Country:US
Practice Address - Phone:901-396-7097
Practice Address - Fax:901-396-8214
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS78581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice