Provider Demographics
NPI:1932567641
Name:TRICE, MONIQUE RENE' (DMD)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:RENE'
Last Name:TRICE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8500
Mailing Address - Fax:901-260-8598
Practice Address - Street 1:969 FRAYSER BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-5977
Practice Address - Country:US
Practice Address - Phone:901-701-2740
Practice Address - Fax:901-260-8598
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021838Medicaid