1790069854 NPI number — PERIODONTAL ASSOCIATES OF JACKSON, P.A.

Table of content: (NPI 1790069854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790069854 NPI number — PERIODONTAL ASSOCIATES OF JACKSON, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIODONTAL ASSOCIATES OF JACKSON, P.A.
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:
1790069854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 BRIARWOOD DR.
Provider Second Line Business Mailing Address:
STE. 101
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-956-1230
Provider Business Mailing Address Fax Number:
601-956-0201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 BRIARWOOD DR.
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-956-1230
Provider Business Practice Location Address Fax Number:
601-956-0201
Provider Enumeration Date:
10/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PARKES
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
601-956-1230

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  2364-87 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 1845-79 , 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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