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General NPI Number Information
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NPI Number | 1790069854
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Entity Type | Organization
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Legal Business Name | PERIODONTAL ASSOCIATES OF JACKSON, P.A.
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Dates
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Enumeration Date | 10/06/2011
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Last Update Date | 10/06/2011
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Provider Practice Location Address
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Address Line | 406 BRIARWOOD DR. STE. 101
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City | JACKSON
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State | MS
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Zip | 39206
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Country | US
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Telephone | 601-956-1230
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Fax | 601-956-0201
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Provider Business Mailing Address
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Address Line | 406 BRIARWOOD DR. STE. 101
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City | JACKSON
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State | MS
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Zip | 39206
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Country | US
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Telephone | 601-956-1230
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Fax | 601-956-0201
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | ROGER B. PARKES
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Credential | D.M.D.
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Telephone | 601-956-1230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2364-87
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 1845-79
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License Number State | MS
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