Provider Demographics
NPI:1386812410
Name:VARNADO, DEWANNA RENEE (DMD)
Entity type:Individual
Prefix:
First Name:DEWANNA
Middle Name:RENEE
Last Name:VARNADO
Suffix:
Gender:F
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:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-582-5461
Practice Address - Street 1:68 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-583-4800
Practice Address - Fax:601-584-7769
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2638-911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1043492770OtherWINDSOR HEALTH GROUP
MS08130001Medicaid
MS9728364OtherAETNA
MS12252606OtherCAQH ID NUMBER