Healthcare Provider Details

I. General information

NPI: 1730219130
Provider Name (Legal Business Name): CHARLES E ATKINS, JR DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 MAIN ST
PHILADELPHIA MS
39350-2562
US

IV. Provider business mailing address

137 PLANTATION DR
COLUMBUS MS
39705-1138
US

V. Phone/Fax

Practice location:
  • Phone: 601-650-0089
  • Fax: 601-650-0056
Mailing address:
  • Phone: 662-329-3931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1284-07
License Number StateMS

VIII. Authorized Official

Name: TORI MORDECAI
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-329-3931