=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659541704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAUTIER DENTAL CENTER P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2008
-----------------------------------------------------
Last Update Date | 03/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713 HIGHWAY 90
-----------------------------------------------------
City | GAUTIER
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39553-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-497-2351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 HIGHWAY 90
-----------------------------------------------------
City | GAUTIER
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39553-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-497-2351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM PARRISH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 228-497-2351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 256790
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------