Provider Demographics
NPI:1780772095
Name:ABIDE, ALBERT KALIL III
Entity type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:KALIL
Last Name:ABIDE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 LAKELAND DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4669
Mailing Address - Country:US
Mailing Address - Phone:601-713-1923
Mailing Address - Fax:601-713-1393
Practice Address - Street 1:764 LAKELAND DR STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4669
Practice Address - Country:US
Practice Address - Phone:601-713-1923
Practice Address - Fax:601-713-1393
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2457891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice