Provider Demographics
NPI:1073715579
Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Entity Type:Organization
Organization Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Other - Org Name:CHOCTAW HEALTH CENTER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHIEF
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-656-5251
Mailing Address - Street 1:210 HOSPITAL CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:MS
Mailing Address - Zip Code:39350-6781
Mailing Address - Country:US
Mailing Address - Phone:601-389-6342
Mailing Address - Fax:601-663-7721
Practice Address - Street 1:210 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-389-6342
Practice Address - Fax:601-663-7721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI BAND OF CHOCTAW INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-05
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9013488Medicaid
MS000010359OtherBC BS DENTAL PROVIDER NUM