Provider First Line Business Practice Location Address:
2500 NORTH STATE ST.
Provider Second Line Business Practice Location Address:
SCHOOL OF DENTISTRY DEPT OF PED AND PUB HEALTH DENT
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-984-6100
Provider Business Practice Location Address Fax Number:
601-984-6103
Provider Enumeration Date:
11/22/2006