Provider Demographics
NPI:1164941936
Name:PONTOTOC FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:PONTOTOC FAMILY DENTAL PLLC
Other - Org Name:COLLIER DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOUPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:4358 LINCOLN ROAD EXT STE 20
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 MAGGIE DR
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-9600
Practice Address - Country:US
Practice Address - Phone:662-488-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty