MEDICARE: SOUTH JACKSON FAMILY DENTAL, PLLC

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	2940-96MS	MS

General Provider Information

NPI Number	:	1821406570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH JACKSON FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 18560
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39404-8560
Country	:	US
Telephone Number	:	601-271-8710
Fax Number	:

Provider Business Practice Location Address
First Line	:	5643 HIGHWAY 18 W
Second Line	:	SUITE G
City	:	JACKSON
State	:	MS
Zip	:	39209-9529
Country	:	US
Telephone Number	:	601-922-0056
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LAKE GARNER
Credential	:	DMD
Telephone Number	:	601-271-8710

Provider Enumeration Date	:	07/25/2014
Last Update Date	:	07/25/2014

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