Healthcare Provider Details

I. General information

NPI: 1679063176
Provider Name (Legal Business Name): FAMILY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PARK AVE
INDIANOLA MS
38751
US

IV. Provider business mailing address

PO BOX 972
INDIANOLA MS
38751-0972
US

V. Phone/Fax

Practice location:
  • Phone: 662-887-1272
  • Fax:
Mailing address:
  • Phone: 662-887-1272
  • Fax: 662-887-6453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number392117
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number273893
License Number StateMS

VIII. Authorized Official

Name: JODI PAGE
Title or Position: INSURANCE BILLING
Credential:
Phone: 662-887-1272