1679580518 NPI number — TERRACE HILL DENTAL CENTER LLC

Table of content: (NPI 1679580518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679580518 NPI number — TERRACE HILL DENTAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRACE HILL DENTAL CENTER 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:
1679580518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6654 U S HIGHWAY 98
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39402-7936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-264-5756
Provider Business Mailing Address Fax Number:
601-264-5013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6654 U S HIGHWAY 98
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-7936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-264-5756
Provider Business Practice Location Address Fax Number:
601-264-5013
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
FELDER
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DENTIST/CO-OWNER
Authorized Official Telephone Number:
601-264-5756

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1771.77 , 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: 1771-77 . This is a "DENTIST LICENSE NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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