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General NPI Number Information
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NPI Number | 1861816670
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Entity Type | Organization
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Legal Business Name | MID TOWN DENTAL
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Dates
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Enumeration Date | 02/13/2014
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Last Update Date | 02/13/2014
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Provider Practice Location Address
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Address Line | 808 N STATE ST SUITE A
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City | JACKSON
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State | MS
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Zip | 39202-2602
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Country | US
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Telephone | 601-355-5275
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Fax |
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Provider Business Mailing Address
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Address Line | 808 N STATE ST
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City | JACKSON
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State | MS
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Zip | 39202-2602
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Country | US
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Telephone | 601-355-5275
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | STEVEY GADDIS
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Credential |
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Telephone | 601-355-5275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 294096
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License Number State | MS
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