Provider Demographics
NPI:1134180557
Name:VESSELL, JIMMY F (DDS)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:F
Last Name:VESSELL
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 1:1011 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2753
Mailing Address - Country:US
Mailing Address - Phone:601-636-6081
Mailing Address - Fax:601-638-5482
Practice Address - Street 1:1011 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2753
Practice Address - Country:US
Practice Address - Phone:601-636-6081
Practice Address - Fax:601-638-5482
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS930-591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS930OtherDELTA DENTAL
MS00064667Medicaid
MS226519OtherTRIGON
MS517629OtherUNITED CONCORDIA