Provider Demographics
NPI:1457485492
Name:MACK, EDWARD MAURICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MAURICE
Last Name:MACK
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 1:2543 FONTAINE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38106-8519
Mailing Address - Country:US
Mailing Address - Phone:901-378-3804
Mailing Address - Fax:
Practice Address - Street 1:5180 PARK AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3521
Practice Address - Country:US
Practice Address - Phone:901-683-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000079481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics