Provider Demographics
NPI:1801965256
Name:NEELY, JOHNNY DEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:DEE
Last Name:NEELY
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 1:1491 CANTON MART RD
Mailing Address - Street 2:BUILDING A SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5411
Mailing Address - Country:US
Mailing Address - Phone:601-991-0044
Mailing Address - Fax:
Practice Address - Street 1:1491 CANTON MART RD
Practice Address - Street 2:BUILDING A SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5411
Practice Address - Country:US
Practice Address - Phone:601-991-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2192-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice