Provider Demographics
NPI:1255433462
Name:ADKISON, WAYNE TRAVIS (DMD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:TRAVIS
Last Name:ADKISON
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 1:4400 MCINNIS AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-2814
Mailing Address - Country:US
Mailing Address - Phone:228-475-0005
Mailing Address - Fax:228-475-0057
Practice Address - Street 1:4400 MCINNIS AVE
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2814
Practice Address - Country:US
Practice Address - Phone:228-475-0005
Practice Address - Fax:228-475-0057
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS195882122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist