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General NPI Number Information
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NPI Number | 1750581906
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Entity Type | Organization
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Legal Business Name | POLK DENTAL CENTER
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Dates
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Enumeration Date | 07/24/2007
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Last Update Date | 07/24/2007
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Provider Practice Location Address
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Address Line | 120 SCARBROUGH ST SUITE B
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City | RICHLAND
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State | MS
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Zip | 39218-9770
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Country | US
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Telephone | 601-932-0606
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Fax | 601-932-0703
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Provider Business Mailing Address
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Address Line | PO BOX 180607
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City | RICHLAND
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State | MS
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Zip | 39218-0607
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Country | US
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Telephone | 601-932-0606
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Fax | 601-932-0703
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. NICKI ASHLEY
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Credential |
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Telephone | 601-932-0606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3138
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3137
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License Number State | MS
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