Provider Demographics
NPI:1619157724
Name:DENNIS, W MIKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:W
Middle Name:MIKE
Last Name:DENNIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:MICHAEL
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4801 OLD CANTON ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:601-981-7122
Mailing Address - Fax:601-981-0569
Practice Address - Street 1:4801 OLD CANTON ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-981-7122
Practice Address - Fax:601-981-0569
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS149072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist