Provider Demographics
NPI:1790857738
Name:UMFRESS, CLASTIE DEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLASTIE
Middle Name:DEAN
Last Name:UMFRESS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 GOODMAN RD E STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9540
Mailing Address - Country:US
Mailing Address - Phone:662-536-2900
Mailing Address - Fax:662-536-2990
Practice Address - Street 1:579 E GOODMAN ROAD SUITE #6
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9433
Practice Address - Country:US
Practice Address - Phone:662-536-2900
Practice Address - Fax:662-536-2990
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3244-021223G0001X
MS3244021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS173192192Medicaid
MSDNT173192192Medicaid