Provider Demographics
NPI:1164559407
Name:BROWN, MARY TISON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TISON
Last Name:BROWN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LAKEWARD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4827
Mailing Address - Country:US
Mailing Address - Phone:601-982-7212
Mailing Address - Fax:601-981-2362
Practice Address - Street 1:2525 LAKEWARD DR STE 102
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4827
Practice Address - Country:US
Practice Address - Phone:601-982-7212
Practice Address - Fax:601-981-2362
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3183-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice