Provider Demographics
NPI:1477725851
Name:CHILDREN'S DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CHET
Authorized Official - Last Name:GATEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-924-4900
Mailing Address - Street 1:539A HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4193
Mailing Address - Country:US
Mailing Address - Phone:601-924-4900
Mailing Address - Fax:
Practice Address - Street 1:539A HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4193
Practice Address - Country:US
Practice Address - Phone:601-924-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660116Medicaid