Provider Demographics
NPI:1982728580
Name:KING, JEREMY DREW (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DREW
Last Name:KING
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 1:1381 JOHNNY JOHNSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-9641
Mailing Address - Country:US
Mailing Address - Phone:601-823-2990
Mailing Address - Fax:601-823-2991
Practice Address - Street 1:1381 JOHNNY JOHNSON DRIVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-9641
Practice Address - Country:US
Practice Address - Phone:601-823-2990
Practice Address - Fax:601-823-2991
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3390061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice