1023107240 NPI number — OXFORD DENTAL CLINIC

Table of content: (NPI 1023107240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023107240 NPI number — OXFORD DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OXFORD DENTAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023107240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2155 SOUTH LAMAR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-2018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-234-5222
Provider Business Mailing Address Fax Number:
662-234-5254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 S LAMAR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655-5223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-234-5222
Provider Business Practice Location Address Fax Number:
662-234-5254
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PACE
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
662-234-5222

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1700-75 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2825-94 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0660083 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0064235 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com