Provider Demographics
NPI:1073708913
Name:ADVANCE DENTAL CLINIC
Entity Type:Organization
Organization Name:ADVANCE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENESSA
Authorized Official - Middle Name:V
Authorized Official - Last Name:TOOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-206-1112
Mailing Address - Street 1:1555 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-1801
Mailing Address - Country:US
Mailing Address - Phone:601-206-1112
Mailing Address - Fax:601-206-1114
Practice Address - Street 1:1555 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-1801
Practice Address - Country:US
Practice Address - Phone:601-206-1112
Practice Address - Fax:601-206-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3314-04122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02674220Medicaid