Healthcare Provider Details

I. General information

NPI: 1710965769
Provider Name (Legal Business Name): JOHN CHARLES GILLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 OLD AIRPORT RD
HATTIESBURG MS
39401-8382
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-583-4800
  • Fax: 601-584-7769
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1363-69
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: