Healthcare Provider Details

I. General information

NPI: 1780755165
Provider Name (Legal Business Name): EUGENE C. BROWN JR. DDS, M.S., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 RIDGEWOOD RD SUITE 103
JACKSON MS
39211-2667
US

IV. Provider business mailing address

5800 RIDGEWOOD RD SUITE 103
JACKSON MS
39211-2667
US

V. Phone/Fax

Practice location:
  • Phone: 160-195-7171
  • Fax: 601-956-8774
Mailing address:
  • Phone: 160-195-7171
  • Fax: 601-956-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1777-77
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: