Healthcare Provider Details

I. General information

NPI: 1669753927
Provider Name (Legal Business Name): MONET KALISHA DUCKSWORTH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONET K SAMUEL

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 11/15/2011
Certification Date:
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: 601-545-3700
  • Fax: 601-450-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3617-11
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: