Healthcare Provider Details

I. General information

NPI: 1023107240
Provider Name (Legal Business Name): OXFORD DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 S LAMAR BLVD
OXFORD MS
38655-5223
US

IV. Provider business mailing address

2155 SOUTH LAMAR BLVD
OXFORD MS
38655-2018
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-5222
  • Fax: 662-234-5254
Mailing address:
  • Phone: 662-234-5222
  • Fax: 662-234-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1700-75
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2825-94
License Number StateMS

VIII. Authorized Official

Name: MR. HENRY J. PACE
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 662-234-5222