Provider Demographics
NPI:1821406570
Name:SOUTH JACKSON FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:SOUTH JACKSON FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:PO BOX 18560
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8560
Mailing Address - Country:US
Mailing Address - Phone:601-271-8710
Mailing Address - Fax:
Practice Address - Street 1:5643 HIGHWAY 18 W
Practice Address - Street 2:SUITE G
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9529
Practice Address - Country:US
Practice Address - Phone:601-922-0056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940-96MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty