Provider Demographics
NPI:1386922474
Name:PENDLETON GREENE, MELODY JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:JEAN
Last Name:PENDLETON GREENE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5126
Mailing Address - Country:US
Mailing Address - Phone:901-674-7132
Mailing Address - Fax:
Practice Address - Street 1:1684 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2583
Practice Address - Country:US
Practice Address - Phone:901-861-9668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9295122300000X, 1223P0221X
MERES90122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524862Medicaid