Provider Demographics
NPI:1740482306
Name:DR. MILTON GARY WALDROP
Entity type:Organization
Organization Name:DR. MILTON GARY WALDROP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:BURNSIDE
Authorized Official - Last Name:JOURDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-328-9123
Mailing Address - Street 1:116 LAWRENCE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-5319
Mailing Address - Country:US
Mailing Address - Phone:662-328-9123
Mailing Address - Fax:662-328-9152
Practice Address - Street 1:116 LAWRENCE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-5319
Practice Address - Country:US
Practice Address - Phone:662-328-9123
Practice Address - Fax:662-328-9152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1024-611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS425669694OtherSS#
MS425669694OtherSS#