Basic Information
| Provider Information | |||||||||
| NPI: | 1417615352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERRY | ||||||||
| FirstName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 BEACH BLVD STE 31 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282731689 | ||||||||
| FaxNumber: | 2283882051 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282731689 | ||||||||
| FaxNumber: | 2283882051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 4081-19 | MS | N | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223G0001X | 4081-19 | MS | Y | Dental Providers | Dentist | General Practice |
No ID Information.