Healthcare Provider Details

I. General information

NPI: 1326265679
Provider Name (Legal Business Name): COMMUNITY DENTAL CARE,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 W SOUTH ST
HERNANDO MS
38632-2269
US

IV. Provider business mailing address

165 W SOUTH ST
HERNANDO MS
38632-2269
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-3994
  • Fax:
Mailing address:
  • Phone: 662-449-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1821-78
License Number StateMS

VIII. Authorized Official

Name: MRS. SHIRLEY S SEYMOUR
Title or Position: SECRETARY
Credential:
Phone: 662-449-3994