Healthcare Provider Details

I. General information

NPI: 1932203585
Provider Name (Legal Business Name): OKOLONA FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 W MAIN STREET
OKOLONA MS
38860
US

IV. Provider business mailing address

233 W MAIN STREET
OKOLONA MS
38860
US

V. Phone/Fax

Practice location:
  • Phone: 662-447-2704
  • Fax: 662-447-2706
Mailing address:
  • Phone: 662-447-2704
  • Fax: 662-447-2706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM D SIMPSON
Title or Position: OWNER
Credential: DMD
Phone: 662-447-2704