Provider Demographics
NPI:1154349967
Name:UNDERWOOD, NORMAN C JR (DENTIST)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:C
Last Name:UNDERWOOD
Suffix:JR
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6745 S SIWELL RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8746
Mailing Address - Country:US
Mailing Address - Phone:601-371-8634
Mailing Address - Fax:601-371-8724
Practice Address - Street 1:6745 S SIWELL RD STE 210
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8746
Practice Address - Country:US
Practice Address - Phone:601-371-8634
Practice Address - Fax:601-371-8724
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2036-831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060285Medicaid
MS00060285Medicaid