Provider Demographics
NPI:1922069715
Name:CUNNINGHAM, GARVIN WALLACE (DDS)
Entity Type:Individual
Prefix:
First Name:GARVIN
Middle Name:WALLACE
Last Name:CUNNINGHAM
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:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:228-374-2713
Practice Address - Street 1:683 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-374-4991
Practice Address - Fax:228-374-3566
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1515721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice