Provider Demographics
NPI:1275750531
Name:AUTUMN RIDGE DENTAL PARTNERSHIP
Entity Type:Organization
Organization Name:AUTUMN RIDGE DENTAL PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:Q
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-289-7076
Mailing Address - Street 1:101 RIDGEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3265
Mailing Address - Country:US
Mailing Address - Phone:662-289-7076
Mailing Address - Fax:662-289-7050
Practice Address - Street 1:101 RIDGEWOOD CIR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3265
Practice Address - Country:US
Practice Address - Phone:662-289-7076
Practice Address - Fax:662-289-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1686-751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014559Medicaid