Provider Demographics
NPI:1497292239
Name:ADVANCED DENTAL CLINIC
Entity Type:Organization
Organization Name:ADVANCED DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:T.
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:4358 LINCOLN RD EXT
Mailing Address - Street 2:SUITE 20
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-271-8710
Mailing Address - Fax:
Practice Address - Street 1:1555 E COUNTY LINE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-271-8710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty