Provider Demographics
NPI:1669753927
Name:DUCKSWORTH, MONET KALISHA (DMD)
Entity type:Individual
Prefix:
First Name:MONET
Middle Name:KALISHA
Last Name:DUCKSWORTH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MONET
Other - Middle Name:K
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:68 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-583-4800
Practice Address - Fax:601-584-7769
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3617-111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015171Medicaid
MS12284817OtherCAQH ID#