Provider Demographics
NPI:1396853701
Name:GARNER, TERRY LAKE (DMD)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LAKE
Last Name:GARNER
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:PO BOX 18560
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404
Mailing Address - Country:US
Mailing Address - Phone:601-271-7300
Mailing Address - Fax:601-271-9097
Practice Address - Street 1:117 THORNHILL DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-271-7300
Practice Address - Fax:601-271-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940 96122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist