Provider Demographics
NPI:1013210624
Name:PEDIATRIC DENTAL GROUP OF HATTIESBURG, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP OF HATTIESBURG, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LINDSEY
Authorized Official - Last Name:BELKNAP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-450-6060
Mailing Address - Street 1:6643 US HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8442
Mailing Address - Country:US
Mailing Address - Phone:601-450-6060
Mailing Address - Fax:601-450-6062
Practice Address - Street 1:6643 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8442
Practice Address - Country:US
Practice Address - Phone:601-450-6060
Practice Address - Fax:601-450-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3394-061223P0221X
MS3044-981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty