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General NPI Number Information
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NPI Number | 1073708913
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Entity Type | Organization
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Legal Business Name | ADVANCE DENTAL CLINIC
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Dates
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Enumeration Date | 09/13/2007
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Last Update Date | 09/13/2007
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Provider Practice Location Address
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Address Line | 1555 E COUNTY LINE RD
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City | JACKSON
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State | MS
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Zip | 39211-1801
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Country | US
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Telephone | 601-206-1112
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Fax | 601-206-1114
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Provider Business Mailing Address
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Address Line | 1555 E COUNTY LINE RD
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City | JACKSON
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State | MS
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Zip | 39211-1801
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Country | US
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Telephone | 601-206-1112
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Fax | 601-206-1114
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. DENESSA V. TOOMBS
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Credential | D.M.D.
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Telephone | 601-206-1112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3314-04
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License Number State | MS
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