Provider Demographics
NPI:1063505840
Name:MAYATTE, EDMOND SHAUN (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:SHAUN
Last Name:MAYATTE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2318
Mailing Address - Country:US
Mailing Address - Phone:601-825-1105
Mailing Address - Fax:601-825-1984
Practice Address - Street 1:22 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2318
Practice Address - Country:US
Practice Address - Phone:601-825-1105
Practice Address - Fax:601-825-1984
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3156-001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice