Provider Demographics
NPI:1548690688
Name:MINOR, CHANDRA M (DMD)
Entity type:Individual
Prefix:DR
First Name:CHANDRA
Middle Name:M
Last Name:MINOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 RIVERWIND DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-5653
Mailing Address - Country:US
Mailing Address - Phone:601-965-9561
Mailing Address - Fax:
Practice Address - Street 1:1047 W GALLMAN RD
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-9452
Practice Address - Country:US
Practice Address - Phone:601-955-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3651-12122300000X
MSOR-484-141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist