Provider Demographics
NPI:1932265592
Name:GADDIS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GADDIS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-693-7913
Mailing Address - Street 1:1460 SUMMER SEAT RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-9270
Mailing Address - Country:US
Mailing Address - Phone:601-693-7913
Mailing Address - Fax:601-483-2217
Practice Address - Street 1:1316 25TH AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3916
Practice Address - Country:US
Practice Address - Phone:601-693-7913
Practice Address - Fax:601-483-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3155-001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015862Medicaid