Provider Demographics
NPI:1154401909
Name:JEFCOAT, FANASY PROKOP (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:FANASY
Middle Name:PROKOP
Last Name:JEFCOAT
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 TIDEWATER LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8927
Mailing Address - Country:US
Mailing Address - Phone:601-605-6511
Mailing Address - Fax:601-605-6508
Practice Address - Street 1:101 WEBSTER CIRCLE
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-605-6511
Practice Address - Fax:601-605-6508
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3251-031223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics