=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861155764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2021
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 E COMMERCE ST
-----------------------------------------------------
City | HERNANDO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38632-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-429-5055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 E COMMERCE ST
-----------------------------------------------------
City | HERNANDO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38632-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | HILLARY THULL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------