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General NPI Number Information
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NPI Number | 1265779052
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Entity Type | Organization
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Legal Business Name | GRANTS FERRY FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/14/2013
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Last Update Date | 01/14/2013
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Provider Practice Location Address
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Address Line | 1075 LAKE VILLAGE CIR
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City | BRANDON
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State | MS
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Zip | 39047-6743
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Country | US
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Telephone | 601-992-1605
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Fax | 601-992-9534
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Provider Business Mailing Address
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Address Line | 1075 LAKE VILLAGE CIR
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City | BRANDON
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State | MS
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Zip | 39047-6743
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Country | US
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Telephone | 601-992-1605
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Fax | 601-992-9534
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARLA RUSHING
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Credential |
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Telephone | 601-992-1605
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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 | 3276-03
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License Number State | MS
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