Organization
DENTAL GROUP OF ELLISVILLE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY LAKE GARNER DMD (OWNER)
(601) 271-8710
Entity
Organization
Contact information
Practice address
97 HAL CROCKER ROAD, ELLISVILLE, MS 39437
(601) 477-3779
(601) 477-3770
Mailing address
97 HAL CROCKER ROAD, ELLISVILLE, MS 39437
(601) 477-3779
(601) 477-3770
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
2940-96
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00660377
—
MS
Enumeration date
08/27/2012
Last updated
03/18/2019
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