Provider Demographics
NPI:1619005717
Name:CHICKASAW DENTAL
Entity Type:Organization
Organization Name:CHICKASAW DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ORPHEUS
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-324-0093
Mailing Address - Street 1:2877 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2023
Mailing Address - Country:US
Mailing Address - Phone:901-324-0093
Mailing Address - Fax:901-324-4029
Practice Address - Street 1:2877 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2023
Practice Address - Country:US
Practice Address - Phone:901-324-0093
Practice Address - Fax:901-324-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225499Medicaid