=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952430878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES E ATKINS, JR DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 499 GLOSTER CREEK VLG STE F-8N
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-678-1028
-----------------------------------------------------
Fax | 662-678-1024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 PLANTATION DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39705-1138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-329-3931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TORI MORDECAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-329-3931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1284-07
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------