Provider Demographics
NPI:1003905381
Name:EVERETT, ROBERT EUGENE JR
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EUGENE
Last Name:EVERETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:EUGENE
Other - Last Name:EVERETT
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2693 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3106
Mailing Address - Country:US
Mailing Address - Phone:228-872-2000
Mailing Address - Fax:
Practice Address - Street 1:2693 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3106
Practice Address - Country:US
Practice Address - Phone:228-872-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3037-98122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist