Healthcare Provider Details

I. General information

NPI: 1093927220
Provider Name (Legal Business Name): DEVEREUX AND NGUYEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 HIGHWAY 11 SUITE C
CARRIERE MS
39426-7145
US

IV. Provider business mailing address

6420 HIGHWAY 11 SUITE C
CARRIERE MS
39426-7145
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-3120
  • Fax: 601-251-0006
Mailing address:
  • Phone: 601-799-3120
  • Fax: 601-251-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2971
License Number StateMS

VIII. Authorized Official

Name: DR. JACK P DEVEREUX
Title or Position: OWNER AND ORTHODONTIST
Credential: D.D.S., M.S.
Phone: 601-799-3120