Provider Demographics
NPI:1164938650
Name:PEDIATRIC DENTISTRY OF CORINTH
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF CORINTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KENNON
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-327-0995
Mailing Address - Street 1:1500 N HARPER RD #5
Mailing Address - Street 2:PEDIATRIC DENTISTRY OF CORINTH
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834
Mailing Address - Country:US
Mailing Address - Phone:662-872-3031
Mailing Address - Fax:662-510-0190
Practice Address - Street 1:1500 N HARPER RD #5
Practice Address - Street 2:PEDIATRIC DENTISTRY OF CORINTH
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-872-3031
Practice Address - Fax:662-510-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2264-861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05705209Medicaid