Provider Demographics
NPI:1346706926
Name:TULLOS, MICHAEL ELLIS (RDH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ELLIS
Last Name:TULLOS
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5807
Mailing Address - Country:US
Mailing Address - Phone:662-836-7483
Mailing Address - Fax:
Practice Address - Street 1:435 NEW BYHALIA RD
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3747
Practice Address - Country:US
Practice Address - Phone:901-612-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7517124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty