Provider Demographics
NPI:1427190750
Name:GANDY, STEPHEN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:GANDY
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 1:971 LAKELAND DRIVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-366-7324
Mailing Address - Fax:601-366-0228
Practice Address - Street 1:971 LAKELAND DRIVE
Practice Address - Street 2:SUITE 225
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-366-7324
Practice Address - Fax:601-366-0228
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2409881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS190000164Medicare ID - Type Unspecified
U37989Medicare UPIN