Provider Demographics
NPI:1790337921
Name:WASSON, KATIE (DMD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WASSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WEST JACKSON STREET
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:769-567-1000
Mailing Address - Fax:769-567-1939
Practice Address - Street 1:115 WEST JACKSON STREET
Practice Address - Street 2:SUITE 1C
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:769-567-1000
Practice Address - Fax:769-567-1939
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4100-091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice