Provider Demographics
NPI:1992067664
Name:SUTTON, AMY GARDNER (DMD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GARDNER
Last Name:SUTTON
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 1:3720 HARDY ST
Mailing Address - Street 2:SUITE 23
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1550
Mailing Address - Country:US
Mailing Address - Phone:601-264-2779
Mailing Address - Fax:601-264-7298
Practice Address - Street 1:3720 HARDY ST
Practice Address - Street 2:SUITE 23
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1550
Practice Address - Country:US
Practice Address - Phone:601-264-2779
Practice Address - Fax:601-264-7298
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3636-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice