Provider Demographics
NPI:1215144795
Name:TATUM, VIRGINIA ANGELICO (DDS)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:ANGELICO
Last Name:TATUM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3110
Mailing Address - Country:US
Mailing Address - Phone:601-261-5500
Mailing Address - Fax:
Practice Address - Street 1:1623 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3110
Practice Address - Country:US
Practice Address - Phone:601-261-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2791-931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice