Provider Demographics
NPI:1780310730
Name:MEDLOCK, GEREMY D (DMD)
Entity type:Individual
Prefix:
First Name:GEREMY
Middle Name:D
Last Name:MEDLOCK
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 1:2856 HOLLY GLEN DR APT G
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-8840
Mailing Address - Country:US
Mailing Address - Phone:803-212-8290
Mailing Address - Fax:
Practice Address - Street 1:1801 MEHARRY BLVD.
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3501
Practice Address - Country:US
Practice Address - Phone:803-212-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12260390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program