Provider Demographics
NPI:1144348889
Name:GRIFFIN, III, MINOR LEONARD (DMD)
Entity type:Individual
Prefix:DR
First Name:MINOR
Middle Name:LEONARD
Last Name:GRIFFIN, III
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4916
Mailing Address - Country:US
Mailing Address - Phone:601-583-1042
Mailing Address - Fax:601-450-0159
Practice Address - Street 1:1903 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4916
Practice Address - Country:US
Practice Address - Phone:601-583-1042
Practice Address - Fax:601-450-0159
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2307-861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0660360Medicaid
MS0660360Medicaid