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General NPI Number Information
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NPI Number | 1437443439
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Entity Type | Organization
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Legal Business Name | WOODVILLE DENTAL CARE LLC
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Dates
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Enumeration Date | 06/07/2011
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Last Update Date | 06/07/2011
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Provider Practice Location Address
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Address Line | 211 HIGHWAY 61 S
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City | WOODVILLE
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State | MS
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Zip | 39669-3586
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Country | US
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Telephone | 601-888-3090
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Fax | 601-888-3095
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Provider Business Mailing Address
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Address Line | 211 HWY 61 S
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City | WOODVILLE
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State | MS
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Zip | 39669-3586
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Country | US
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Telephone | 601-888-3090
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Fax | 601-888-3095
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Authorized Official
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Title or Position | PRESIDENT
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Name | TERRY MENELEY DEVALL
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Credential | DMD
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Telephone | 601-888-3090
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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 | 228586
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License Number State | MS
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