Healthcare Provider Details

I. General information

NPI: 1780303677
Provider Name (Legal Business Name): NETTLETON DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 MAIN ST
NETTLETON MS
38858-6012
US

IV. Provider business mailing address

228 MAIN ST
NETTLETON MS
38858-6012
US

V. Phone/Fax

Practice location:
  • Phone: 662-963-7338
  • Fax:
Mailing address:
  • Phone: 662-963-7338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMBRIE GOODMAN
Title or Position: DENTIST
Credential: DMD
Phone: 662-571-8760