Healthcare Provider Details

I. General information

NPI: 1275536252
Provider Name (Legal Business Name): DANIEL QUON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 RIDGEWOOD RD STE 102
JACKSON MS
39211-2667
US

IV. Provider business mailing address

5800 RIDGEWOOD RD STE 102
JACKSON MS
39211-2667
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-1207
  • Fax: 601-957-0602
Mailing address:
  • Phone: 601-957-1207
  • Fax: 601-957-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number1849-79
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1849-79
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: