Healthcare Provider Details

I. General information

NPI: 1124245444
Provider Name (Legal Business Name): DESOTO FAMILY DENTAL CARE,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BYHALIA RD
HERNANDO MS
38632-1319
US

IV. Provider business mailing address

460 BYHALIA RD
HERNANDO MS
38632-1319
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5239
  • Fax: 662-449-0758
Mailing address:
  • Phone: 662-429-5239
  • Fax: 662-449-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1472-71
License Number StateMS

VIII. Authorized Official

Name: MRS. SHIRLEY S SEYMOUR
Title or Position: SECRETARY
Credential:
Phone: 662-429-5239