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General NPI Number Information
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NPI Number | 1023386372
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Entity Type | Organization
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Legal Business Name | CRYSTAL SPRINGS DENTAL CENTER, LLC
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Dates
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Enumeration Date | 12/01/2011
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Last Update Date | 12/06/2011
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Provider Practice Location Address
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Address Line | 304 HARMONY RD
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City | CRYSTAL SPRINGS
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State | MS
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Zip | 39059-2809
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Country | US
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Telephone | 901-282-5706
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Fax |
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Provider Business Mailing Address
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Address Line | 304 HARMONY RD
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City | CRYSTAL SPRINGS
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State | MS
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Zip | 39059-2809
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | DR. TERRANCE L WARE
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Credential | DDS
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Telephone | 901-282-5706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3439-07
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License Number State | MS
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