Provider Demographics
NPI:1508293531
Name:MARQUIS DENTAL CENTER PA
Entity Type:Organization
Organization Name:MARQUIS DENTAL CENTER PA
Other - Org Name:RENEW DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MARQUIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-823-7900
Mailing Address - Street 1:1013 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-1907
Mailing Address - Country:US
Mailing Address - Phone:662-823-7900
Mailing Address - Fax:662-823-7920
Practice Address - Street 1:1013 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-1907
Practice Address - Country:US
Practice Address - Phone:662-823-7900
Practice Address - Fax:662-823-7920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARQUIS DENTAL CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-04
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1452-71332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6924950001Medicare NSC