Provider Demographics
NPI:1790901890
Name:GARY, LEE D (DMD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:D
Last Name:GARY
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 1:102 E. PINEVIEW DR.
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-992-1285
Mailing Address - Fax:601-992-6526
Practice Address - Street 1:102 E. PINEVIEW DR.
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-992-1285
Practice Address - Fax:601-992-6526
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3328-051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05373770Medicaid