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General NPI Number Information
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NPI Number | 1215205331
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Entity Type | Organization
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Legal Business Name | QUITMAN FAMILY DENTAL, PLLC
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Dates
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Enumeration Date | 12/03/2011
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Last Update Date | 12/03/2011
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Provider Practice Location Address
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Address Line | 105 E DONALD ST
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City | QUITMAN
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State | MS
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Zip | 39355-2342
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Country | US
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Telephone | 601-776-2511
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Fax | 601-776-8993
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Provider Business Mailing Address
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Address Line | PO BOX 2926
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City | MERIDIAN
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State | MS
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Zip | 39302-2926
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Country | US
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Telephone | 601-776-2511
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Fax | 601-776-8993
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Authorized Official
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Title or Position | DENTIST, PARTNER
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Name | DR. WILLIAM BROCK MARTIN
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Credential | DMD, JD
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Telephone | 601-776-2511
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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 | 1841-79
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3396-06
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License Number State | MS
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