Provider Demographics
NPI:1114055167
Name:GOLDEN TRIANGLE PERIODONTAL CENTER
Entity Type:Organization
Organization Name:GOLDEN TRIANGLE PERIODONTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:STARR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-329-2696
Mailing Address - Street 1:2900 BLUECUTT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1470
Mailing Address - Country:US
Mailing Address - Phone:662-329-2696
Mailing Address - Fax:
Practice Address - Street 1:2900 BLUECUTT RD
Practice Address - Street 2:SUITE 3
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1470
Practice Address - Country:US
Practice Address - Phone:662-329-2696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPER154-881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty