Provider Demographics
NPI:1942569439
Name:LEVERETT, JOSEPH TYLER (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:TYLER
Last Name:LEVERETT
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 1:1621 PASS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4341
Mailing Address - Country:US
Mailing Address - Phone:228-436-4401
Mailing Address - Fax:
Practice Address - Street 1:1621 PASS RD
Practice Address - Street 2:SUITE C
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4341
Practice Address - Country:US
Practice Address - Phone:228-436-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3631-12122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist