Provider Demographics
NPI:1275536252
Name:QUON, DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:QUON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5800 RIDGEWOOD RD
Mailing Address - Street 2:STE 102
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2667
Mailing Address - Country:US
Mailing Address - Phone:601-957-1207
Mailing Address - Fax:601-957-0602
Practice Address - Street 1:5800 RIDGEWOOD RD
Practice Address - Street 2:STE 102
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2667
Practice Address - Country:US
Practice Address - Phone:601-957-1207
Practice Address - Fax:601-957-0602
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS1849-79204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
190000037Medicare ID - Type Unspecified
T20884Medicare UPIN