Provider Demographics
NPI:1477758548
Name:VINCENT, GERALD CLIVE (DDS)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:CLIVE
Last Name:VINCENT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5442 WATKINS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206
Mailing Address - Country:US
Mailing Address - Phone:601-366-6522
Mailing Address - Fax:601-366-0411
Practice Address - Street 1:5442 WATKINS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-366-6522
Practice Address - Fax:601-366-0411
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS296696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660160Medicaid