Healthcare Provider Details

I. General information

NPI: 1871915397
Provider Name (Legal Business Name): CENTRAL MISSISSIPPI OUTREACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 D NEWMAN RD
UTICA MS
39175-9039
US

IV. Provider business mailing address

2160 D NEWMAN RD
UTICA MS
39175-9039
US

V. Phone/Fax

Practice location:
  • Phone: 601-214-3041
  • Fax:
Mailing address:
  • Phone: 601-214-3041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3581-11
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT J HAUPTMAN
Title or Position: PARTNER
Credential: D.M.D.
Phone: 601-214-3041