1598995755 NPI number — NORTH MS COMMUNITY DENTAL CLINIC

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 1598995755 NPI number — NORTH MS COMMUNITY DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH MS COMMUNITY 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:
1598995755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39236-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-561-1045
Provider Business Mailing Address Fax Number:
662-561-1181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 HIGHWAY 6 E
Provider Second Line Business Practice Location Address:
EAST OAKS SHOPPING CENTER
Provider Business Practice Location Address City Name:
BATESVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38606-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-561-1045
Provider Business Practice Location Address Fax Number:
662-561-1181
Provider Enumeration Date:
07/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NEELY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
662-561-1045

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2650-91 , 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: 00660095 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04581039 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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