MEDICARE: DR. TONY LAVELLE HUMPHRIES D. M. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1977-82	MS

General Provider Information

NPI Number	:	1497731236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TONY LAVELLE HUMPHRIES D. M. D.

Provider Business Mailing Address
First Line	:	144 OLD HIGHWAY 98 E
Second Line	:
City	:	COLUMBIA
State	:	MS
Zip	:	39429-6447
Country	:	US
Telephone Number	:	601-736-5681
Fax Number	:	601-736-5606

Provider Business Practice Location Address
First Line	:	144 OLD HIGHWAY 98 E
Second Line	:
City	:	COLUMBIA
State	:	MS
Zip	:	39429-6447
Country	:	US
Telephone Number	:	601-736-5681
Fax Number	:	601-736-5606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/08/2007

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