Provider Demographics
NPI:1194938126
Name:GATEWOOD, HIRAM ALFONSO JR (DMD)
Entity type:Individual
Prefix:DR
First Name:HIRAM
Middle Name:ALFONSO
Last Name:GATEWOOD
Suffix:JR
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 1:450 MAIN ST. PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154
Mailing Address - Country:US
Mailing Address - Phone:601-857-5021
Mailing Address - Fax:601-857-2106
Practice Address - Street 1:450 MAIN ST.
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154
Practice Address - Country:US
Practice Address - Phone:601-857-5021
Practice Address - Fax:601-857-2106
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1926-811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice