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General NPI Number Information
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NPI Number | 1245539808
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Entity Type | Organization
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Legal Business Name | COMMUNITY DENTAL, INC
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 908 MUNICIPAL DR
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City | BRANDON
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State | MS
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Zip | 39042-2973
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Country | US
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Telephone | 601-825-2150
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Fax | 601-825-2792
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Provider Business Mailing Address
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Address Line | 908 MUNICIPAL DR
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City | BRANDON
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State | MS
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Zip | 39042-2973
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Country | US
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Telephone | 601-825-2150
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Fax | 601-825-2792
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Authorized Official
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Title or Position | DENTIST/PRESIDENT
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Name | DR. JAMAAL EDWIN LONGINO
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Credential | D.M.D.
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Telephone | 601-825-2150
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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 | 3483-08
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License Number State | MS
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