Provider Demographics
NPI:1063503126
Name:LANDRY, RALPH JOSEPH (DDD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:JOSEPH
Last Name:LANDRY
Suffix:
Gender:M
Credentials:DDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4410
Mailing Address - Country:US
Mailing Address - Phone:662-624-8114
Mailing Address - Fax:
Practice Address - Street 1:512 1ST ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4410
Practice Address - Country:US
Practice Address - Phone:662-624-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS2183-851223G0001X
MS2181-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060140Medicaid