Healthcare Provider Details

I. General information

NPI: 1780083311
Provider Name (Legal Business Name): IGNACIO VELASCO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6090
  • Fax: 601-984-4949
Mailing address:
  • Phone: 601-984-6090
  • Fax: 601-984-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number15341809-8
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOS-538-17
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: