MEDICARE: DR. MILTON GARY WALDROP

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	1223G0001X	General Practice Dentistry	1024-61	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	425669694	OTHER	MS	SS#

General Provider Information

NPI Number	:	1740482306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. MILTON GARY WALDROP

Provider Business Mailing Address
First Line	:	116 LAWRENCE DR
Second Line	:	SUITE 1
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5319
Country	:	US
Telephone Number	:	662-328-9123
Fax Number	:	662-328-9152

Provider Business Practice Location Address
First Line	:	116 LAWRENCE DR
Second Line	:	SUITE 1
City	:	COLUMBUS
State	:	MS
Zip	:	39702-5319
Country	:	US
Telephone Number	:	662-328-9123
Fax Number	:	662-328-9152

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KRIS BURNSIDE JOURDAN
Credential	:
Telephone Number	:	662-328-9123

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/01/2008

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