Provider Demographics
NPI:1144230327
Name:NEELY, WILLIAM THOMAS III (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:NEELY
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13409
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3409
Mailing Address - Country:US
Mailing Address - Phone:662-561-1045
Mailing Address - Fax:601-829-3108
Practice Address - Street 1:560 HIGHWAY 6 E
Practice Address - Street 2:EAST OAKS SHOPPING CENTER
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-3002
Practice Address - Country:US
Practice Address - Phone:662-561-1045
Practice Address - Fax:662-561-1181
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2650911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660095Medicaid