Provider Demographics
NPI:1710111034
Name:TANKERSLEY, JERRY DEANE (DMD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEANE
Last Name:TANKERSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HIGHWAY 322
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4717
Mailing Address - Country:US
Mailing Address - Phone:662-624-2504
Mailing Address - Fax:
Practice Address - Street 1:800 OHIO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7200
Practice Address - Country:US
Practice Address - Phone:662-624-4292
Practice Address - Fax:662-627-3629
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2300-86122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist