1790801298 NPI number — CATHERINE JOHNSON MINCY, DDS

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 1790801298 NPI number — CATHERINE JOHNSON MINCY, DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATHERINE JOHNSON MINCY, DDS
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:
CATHERINE JOHNSON MINCY, DDS
Provider Other Organization Name Type Code:
4
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:
1790801298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
607 W CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38829-2647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-728-8133
Provider Business Mailing Address Fax Number:
662-728-6903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 W CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38829-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-728-8133
Provider Business Practice Location Address Fax Number:
662-728-6903
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MINCY
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-728-8133

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3009-97 , 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: 00660215 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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