Provider Demographics
NPI:1235497108
Name:VICKSBURG FAMILY DENTAL
Entity Type:Organization
Organization Name:VICKSBURG FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-636-5321
Mailing Address - Street 1:1212 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-3137
Mailing Address - Country:US
Mailing Address - Phone:601-636-5321
Mailing Address - Fax:601-883-2366
Practice Address - Street 1:1212 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-636-5321
Practice Address - Fax:601-883-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940-96MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty