Provider Demographics
NPI:1184308835
Name:BURKS, PEYTON (DMD)
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:BURKS
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 1:1020 WHITSETT WALK
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6158
Mailing Address - Country:US
Mailing Address - Phone:601-344-7677
Mailing Address - Fax:
Practice Address - Street 1:4358 LINCOLN ROAD EXT
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3275
Practice Address - Country:US
Practice Address - Phone:601-271-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4378-231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice