Provider Demographics
NPI:1881777670
Name:PAYNE, JACKSON LEE II (DDS)
Entity type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:LEE
Last Name:PAYNE
Suffix:II
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 1:3574 HICKORY HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115
Mailing Address - Country:US
Mailing Address - Phone:901-365-9054
Mailing Address - Fax:901-365-1159
Practice Address - Street 1:3574 HICKORY HILL ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115
Practice Address - Country:US
Practice Address - Phone:901-365-9054
Practice Address - Fax:901-365-1159
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS5420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225937Medicaid