Provider Demographics
NPI:1528160140
Name:GADDIS, ANDREA RENAE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:RENAE
Last Name:GADDIS
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 1:1426 SUMMER SEAT RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-9270
Mailing Address - Country:US
Mailing Address - Phone:601-693-7918
Mailing Address - Fax:601-483-2217
Practice Address - Street 1:1316 25TH AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3916
Practice Address - Country:US
Practice Address - Phone:601-693-7913
Practice Address - Fax:601-483-2217
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3155-001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660373Medicaid