Provider Demographics
NPI:1679627335
Name:MINCY, CATHERINE JOHNSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:JOHNSON
Last Name:MINCY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-8294
Mailing Address - Country:US
Mailing Address - Phone:662-728-8133
Mailing Address - Fax:662-728-6903
Practice Address - Street 1:607 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2647
Practice Address - Country:US
Practice Address - Phone:662-728-5199
Practice Address - Fax:662-728-6903
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3009-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015740Medicaid