1104151265 NPI number — HUMPHREYS DENTAL, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104151265 NPI number — HUMPHREYS DENTAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUMPHREYS DENTAL, LLC
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:
1104151265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 SHELBY SPEIGHTS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PURVIS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-794-8115
Provider Business Mailing Address Fax Number:
601-794-8115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 SHELBY SPEIGHTS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PURVIS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-794-8115
Provider Business Practice Location Address Fax Number:
601-794-8115
Provider Enumeration Date:
10/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HUMPHREYS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
CHANDLER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-794-8115

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3329-05 , 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)





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