Provider Demographics
NPI:1568577039
Name:STORY, DANIEL BOBBY II
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BOBBY
Last Name:STORY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2667
Mailing Address - Country:US
Mailing Address - Phone:601-956-9850
Mailing Address - Fax:601-956-9852
Practice Address - Street 1:5800 RIDGEWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2667
Practice Address - Country:US
Practice Address - Phone:601-956-9850
Practice Address - Fax:601-956-9852
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2202-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060402Medicaid