Provider Demographics
NPI:1821150194
Name:CHANEY, MARTIN V (DMD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:V
Last Name:CHANEY
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 1:111 VIRGINIA RDG
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-7712
Mailing Address - Country:US
Mailing Address - Phone:601-634-6080
Mailing Address - Fax:601-634-6081
Practice Address - Street 1:3205 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5350
Practice Address - Country:US
Practice Address - Phone:601-634-6080
Practice Address - Fax:601-634-6081
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060033Medicaid