Healthcare Provider Details

I. General information

NPI: 1396033957
Provider Name (Legal Business Name): WARREN BLAKE MAHARREY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 S MADISON ST
TUPELO MS
38801-6309
US

IV. Provider business mailing address

1043 S MADISON ST
TUPELO MS
38801-6309
US

V. Phone/Fax

Practice location:
  • Phone: 662-842-8200
  • Fax: 662-844-3157
Mailing address:
  • Phone: 662-842-8200
  • Fax: 662-844-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3624-11
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: