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NPI Code Detail

MEDICARE: JERRY DEANE TANKERSLEY D.M.D.

MEDICARE: JERRY DEANE TANKERSLEY 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
1122300000XDentist2300-86MS

General Provider Information

NPI Number : 1710111034
Entity Type Code : Individual
Provider Name (Legal Business Name) : JERRY DEANE TANKERSLEY D.M.D.
Provider Business Mailing Address
First Line : 510 HIGHWAY 322
Second Line :
City : CLARKSDALE
State : MS
Zip : 38614-4717
Country : US
Telephone Number : 662-624-2504
Fax Number :
Provider Business Practice Location Address
First Line : 800 OHIO AVE
Second Line :
City : CLARKSDALE
State : MS
Zip : 38614-7200
Country : US
Telephone Number : 662-624-4292
Fax Number : 662-627-3629
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/14/2009
Last Update Date : 06/30/2009

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