Provider Demographics
NPI:1205011608
Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Other - Org Name:TAYLORSVILLE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:411 WILLIS STREET
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39168-0559
Mailing Address - Country:US
Mailing Address - Phone:601-785-4770
Mailing Address - Fax:601-785-4831
Practice Address - Street 1:411 WILLIS ST
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168
Practice Address - Country:US
Practice Address - Phone:601-785-4770
Practice Address - Fax:601-785-4831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS133268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty