Provider Demographics
NPI:1275629164
Name:PATTI, DANIEL JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:PATTI
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 1:103 NOBLE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3623
Mailing Address - Country:US
Mailing Address - Phone:601-833-0207
Mailing Address - Fax:
Practice Address - Street 1:439 N JACKSON ST STE E
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2912
Practice Address - Country:US
Practice Address - Phone:601-833-0777
Practice Address - Fax:601-833-6606
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2095-841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07831757Medicaid
MS839931OtherUNITED CONCORDIA