Provider Demographics
NPI:1629155197
Name:MCCANN, BILLY W JR
Entity Type:Individual
Prefix:DR
First Name:BILLY
Middle Name:W
Last Name:MCCANN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:BILLY
Other - Middle Name:W
Other - Last Name:MCCANN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:5885 RIDGEWAY CENTER PKWY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-4055
Mailing Address - Country:US
Mailing Address - Phone:901-767-9200
Mailing Address - Fax:901-767-9422
Practice Address - Street 1:5885 RIDGEWAY CENTER PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4055
Practice Address - Country:US
Practice Address - Phone:901-767-9200
Practice Address - Fax:901-767-9422
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS54011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0016039Medicaid