Provider Demographics
NPI:1255483186
Name:PICAYUNE GENERAL DENTISTRY, INC.
Entity Type:Organization
Organization Name:PICAYUNE GENERAL DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-798-0500
Mailing Address - Street 1:500 GOODYEAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3217
Mailing Address - Country:US
Mailing Address - Phone:601-798-0500
Mailing Address - Fax:601-799-0141
Practice Address - Street 1:500 GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3217
Practice Address - Country:US
Practice Address - Phone:601-798-0500
Practice Address - Fax:601-799-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3213-021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty