Provider Demographics
NPI:1467519827
Name:TULLOS FAMILY DENTISTRY, PA
Entity Type:Organization
Organization Name:TULLOS FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:SULLIVAN
Authorized Official - Last Name:TULLOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-782-9909
Mailing Address - Street 1:276 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6016
Mailing Address - Country:US
Mailing Address - Phone:601-782-9909
Mailing Address - Fax:601-782-9133
Practice Address - Street 1:276 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6016
Practice Address - Country:US
Practice Address - Phone:601-782-9909
Practice Address - Fax:601-782-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3265-03122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00529717Medicaid