Provider Demographics
NPI:1134300569
Name:STUCKEY, VICTOR WARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:WARD
Last Name:STUCKEY
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 1:912 MEDALLION DR.
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930
Mailing Address - Country:US
Mailing Address - Phone:662-453-5143
Mailing Address - Fax:662-453-5143
Practice Address - Street 1:912 MEDALLION DR.
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930
Practice Address - Country:US
Practice Address - Phone:662-453-5143
Practice Address - Fax:662-453-5143
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130451223G0001X
MS3620-111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05481207Medicaid