Provider Demographics
NPI:1164579504
Name:PERKINS, TERESA MIXON (DMD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:MIXON
Last Name:PERKINS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:M
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:5550 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4024
Mailing Address - Country:US
Mailing Address - Phone:601-398-6434
Mailing Address - Fax:601-981-9304
Practice Address - Street 1:5550 RIDGEWOOD RD STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4024
Practice Address - Country:US
Practice Address - Phone:601-981-9303
Practice Address - Fax:601-981-9304
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47491223P0221X
MSPEDO165891223P0221X
MS2421881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1847496Medicaid
MS02058365Medicaid