=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528696184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA AND OMEGA DENTISTRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 03/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 E MAIN ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39645-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-551-2003
-----------------------------------------------------
Fax | 601-657-5936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 695
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39645-0695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-551-2003
-----------------------------------------------------
Fax | 601-657-5936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SARAH ASHLEY CASEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-551-2003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------