Provider Demographics
NPI:1093919839
Name:GUNDY, PAUL DEVON (DMD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DEVON
Last Name:GUNDY
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 1:101 RIDGEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3265
Mailing Address - Country:US
Mailing Address - Phone:662-289-7076
Mailing Address - Fax:662-289-7050
Practice Address - Street 1:101 RIDGEWOOD CIR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3265
Practice Address - Country:US
Practice Address - Phone:662-289-7076
Practice Address - Fax:662-289-7050
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3415-07122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014559Medicaid