Provider Demographics
NPI:1790069854
Name:PERIODONTAL ASSOCIATES OF JACKSON, P.A.
Entity Type:Organization
Organization Name:PERIODONTAL ASSOCIATES OF JACKSON, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:PARKES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-956-1230
Mailing Address - Street 1:406 BRIARWOOD DR.
Mailing Address - Street 2:STE. 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206
Mailing Address - Country:US
Mailing Address - Phone:601-956-1230
Mailing Address - Fax:601-956-0201
Practice Address - Street 1:406 BRIARWOOD DR.
Practice Address - Street 2:STE. 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-956-1230
Practice Address - Fax:601-956-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1845-791223P0300X
MS2364-871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty