Provider Demographics
NPI:1154401172
Name:POTTS, DENESSA V (DMD)
Entity type:Individual
Prefix:
First Name:DENESSA
Middle Name:V
Last Name:POTTS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:DENESSA
Other - Middle Name:V
Other - Last Name:TOOMBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1668 W PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5332
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:601-859-9477
Practice Address - Street 1:1668 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5332
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-9477
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3314-04122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03588521Medicaid