Provider Demographics
NPI:1023386372
Name:CRYSTAL SPRINGS DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:CRYSTAL SPRINGS DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-282-5706
Mailing Address - Street 1:304 HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 HARMONY RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2809
Practice Address - Country:US
Practice Address - Phone:901-282-5706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3439-07261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental