Healthcare Provider Details

I. General information

NPI: 1578867115
Provider Name (Legal Business Name): MEDICAL ARTS DENTAL GROUP OF CLINTON P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MORRISON DR
CLINTON MS
39056-5239
US

IV. Provider business mailing address

315 MORRISON DR
CLINTON MS
39056-5239
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-5163
  • Fax: 601-925-5184
Mailing address:
  • Phone: 601-925-5163
  • Fax: 601-925-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number228886
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT J NEELY
Title or Position: DENTIST
Credential: DMD
Phone: 601-925-5163