Provider Demographics
NPI:1396103933
Name:WARREN, DEREK (DMD , MS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
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 1:6668 HIGHWAY 98 WEST
Mailing Address - Street 2:SUITE G
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-475-9608
Mailing Address - Fax:
Practice Address - Street 1:6668 HIGHWAY 98 WEST
Practice Address - Street 2:SUITE G
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-475-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3852-161223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06227838Medicaid