Healthcare Provider Details

I. General information

NPI: 1912077082
Provider Name (Legal Business Name): CALLAWAY ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STARR AVE STE D
STARKVILLE MS
39759
US

IV. Provider business mailing address

100 STARR AVE STE D
STARKVILLE MS
39759
US

V. Phone/Fax

Practice location:
  • Phone: 662-615-4225
  • Fax: 662-615-4288
Mailing address:
  • Phone: 662-615-4225
  • Fax: 662-615-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number299197
License Number StateMS

VIII. Authorized Official

Name: COOPER E CALLAWAY
Title or Position: PRESIDENT
Credential: DMD MS
Phone: 662-615-4225