Provider Demographics
NPI:1073985925
Name:DECATUR DENTAL, LLC
Entity Type:Organization
Organization Name:DECATUR DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:H
Authorized Official - Last Name:POLLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:601-362-1118
Mailing Address - Street 1:1836 CRANE RIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4901
Mailing Address - Country:US
Mailing Address - Phone:601-362-1118
Mailing Address - Fax:601-362-3113
Practice Address - Street 1:68 FOURTH AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MS
Practice Address - Zip Code:39327-9713
Practice Address - Country:US
Practice Address - Phone:601-635-2340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3402-06261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental