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General NPI Number Information
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NPI Number | 1669365110
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Entity Type | Individual
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Provider Name | JACOB KEITH FANNING DMD
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Gender | Male
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Dates
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Enumeration Date | 06/02/2025
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 301 HOSPITAL RD
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City | STARKVILLE
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State | MS
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Zip | 39759-2155
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Country | US
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Telephone | 662-323-3245
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Fax |
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Provider Business Mailing Address
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Address Line | 10630 ROAD 573
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City | PHILADELPHIA
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State | MS
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Zip | 39350-8304
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Country | US
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Telephone | 601-781-7474
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 111164
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License Number State | MS
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