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General NPI Number Information
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NPI Number | 1679063176
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Entity Type | Organization
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Legal Business Name | FAMILY DENTAL CARE
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Dates
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Enumeration Date | 05/10/2018
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 501 PARK AVE
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City | INDIANOLA
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State | MS
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Zip | 38751
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Country | US
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Telephone | 662-887-1272
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 972
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City | INDIANOLA
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State | MS
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Zip | 38751-0972
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Country | US
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Telephone | 662-887-1272
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Fax | 662-887-6453
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Authorized Official
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Title or Position | INSURANCE BILLING
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Name | JODI PAGE
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Credential |
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Telephone | 662-887-1272
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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 | 392117
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 273893
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License Number State | MS
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