Healthcare Provider Details

I. General information

NPI: 1750403440
Provider Name (Legal Business Name): GREGGORY E THARP DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 FLOWOOD DRIVE
JACKSON MS
39232
US

IV. Provider business mailing address

2695 FLOWOOD DR.
FLOWOOD MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-4100
  • Fax: 601-939-4081
Mailing address:
  • Phone: 601-939-4100
  • Fax: 601-939-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberPROS-353-02
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: