Provider Demographics
NPI:1235240722
Name:LACKEY, MARK A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:LACKEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-1421
Mailing Address - Country:US
Mailing Address - Phone:901-448-1883
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-5028
Practice Address - Country:US
Practice Address - Phone:901-448-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist