Provider Demographics
NPI:1316185572
Name:VANN, WILLIAM HENRY JR (DDS, MAED)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HENRY
Last Name:VANN
Suffix:JR
Gender:M
Credentials:DDS, MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 431
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:MS
Mailing Address - Zip Code:39455
Mailing Address - Country:US
Mailing Address - Phone:601-796-8449
Mailing Address - Fax:601-796-9225
Practice Address - Street 1:7935 U.S. HWY 11
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455
Practice Address - Country:US
Practice Address - Phone:601-796-8449
Practice Address - Fax:601-796-9225
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1736-761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064465Medicaid