Provider Demographics
NPI:1265744510
Name:PARKER, JEREMY WAYNE (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WAYNE
Last Name:PARKER
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 1:4299 POPPS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2363
Mailing Address - Country:US
Mailing Address - Phone:228-392-0509
Mailing Address - Fax:228-392-8709
Practice Address - Street 1:4299 POPPS FERRY RD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2363
Practice Address - Country:US
Practice Address - Phone:228-392-0509
Practice Address - Fax:228-392-8709
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3553-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice