Provider Demographics
NPI:1538330444
Name:FLORENCE DENTAL CLINIC
Entity Type:Organization
Organization Name:FLORENCE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:604-845-2386
Mailing Address - Street 1:PO BOX 97632
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39288-7632
Mailing Address - Country:US
Mailing Address - Phone:601-845-2386
Mailing Address - Fax:601-845-1470
Practice Address - Street 1:129 EARL CLARK DRIVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-845-2386
Practice Address - Fax:601-845-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24011223G0001X
MS31821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015190Medicaid