Provider Demographics
NPI:1215205331
Name:QUITMAN FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:QUITMAN FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BROCK
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, JD
Authorized Official - Phone:601-776-2511
Mailing Address - Street 1:PO BOX 2926
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2926
Mailing Address - Country:US
Mailing Address - Phone:601-776-2511
Mailing Address - Fax:601-776-8993
Practice Address - Street 1:105 E DONALD ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2342
Practice Address - Country:US
Practice Address - Phone:601-776-2511
Practice Address - Fax:601-776-8993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-03
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1841-79122300000X
MS3396-061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty