Provider Demographics
NPI:1760525174
Name:SCHOOL OF DENTISTRY
Entity Type:Organization
Organization Name:SCHOOL OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN OF CLINICAL AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-984-6155
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6155
Mailing Address - Fax:601-815-3901
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6155
Practice Address - Fax:601-815-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013378Medicaid