1063666584 NPI number — DESOTO COUNTY FAMILY DENTISTRY, P.L.L.C.

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 1063666584 NPI number — DESOTO COUNTY FAMILY DENTISTRY, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESOTO COUNTY FAMILY DENTISTRY, P.L.L.C.
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:
1063666584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2631 MCINGVALE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
HERNANDO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38632-0524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-409-9843
Provider Business Mailing Address Fax Number:
662-429-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2631 MCINGVALE RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HERNANDO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38632-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-429-3000
Provider Business Practice Location Address Fax Number:
662-429-3008
Provider Enumeration Date:
11/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
MARSHAL
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
662-429-3000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3584-08 , 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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