Provider Demographics
NPI:1568199107
Name:MISSISSIPPI DENTAL ARTS
Entity Type:Organization
Organization Name:MISSISSIPPI DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FAVRE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:228-254-1212
Mailing Address - Street 1:121 E SECOND ST
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-4442
Mailing Address - Country:US
Mailing Address - Phone:228-254-1212
Mailing Address - Fax:228-254-1213
Practice Address - Street 1:121 E SECOND ST
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4442
Practice Address - Country:US
Practice Address - Phone:228-254-1212
Practice Address - Fax:228-254-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty