Healthcare Provider Details

I. General information

NPI: 1750581906
Provider Name (Legal Business Name): POLK DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SCARBROUGH ST SUITE B
RICHLAND MS
39218-9770
US

IV. Provider business mailing address

PO BOX 180607
RICHLAND MS
39218-0607
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-0606
  • Fax: 601-932-0703
Mailing address:
  • Phone: 601-932-0606
  • Fax: 601-932-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3138
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3137
License Number StateMS

VIII. Authorized Official

Name: MRS. NICKI ASHLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-932-0606