Provider Demographics
NPI:1083295844
Name:ARCHUSA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ARCHUSA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:MCNERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-927-5961
Mailing Address - Street 1:99 HIGHWAY 511
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-8899
Mailing Address - Country:US
Mailing Address - Phone:601-927-5961
Mailing Address - Fax:
Practice Address - Street 1:99 HIGHWAY 511
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-8899
Practice Address - Country:US
Practice Address - Phone:601-776-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGELESS INTENTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-14
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1518564210Medicaid