Healthcare Provider Details

I. General information

NPI: 1982726824
Provider Name (Legal Business Name): LUMBERTON DENTAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

7935 US HWY 11
LUMBERTON MS
39455
US

IV. Provider business mailing address

PO BOX 431
LUMBERTON MS
39455
US

V. Phone/Fax

Practice location:
  • Phone: 601-796-8449
  • Fax: 601-796-9225
Mailing address:
  • Phone: 601-796-8449
  • Fax: 601-796-9225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number173676
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIAM HENRY VANN JR.
Title or Position: GENERAL DENTIST PRESIDENT
Credential: DDS
Phone: 601-796-8449