Provider Demographics
NPI:1568567477
Name:CANTON COMMUNITYDENTALCLINICLLC
Entity Type:Organization
Organization Name:CANTON COMMUNITYDENTALCLINICLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:TERELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-855-5885
Mailing Address - Street 1:512 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4254
Mailing Address - Country:US
Mailing Address - Phone:601-855-5885
Mailing Address - Fax:601-855-2833
Practice Address - Street 1:512 W FULTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4254
Practice Address - Country:US
Practice Address - Phone:601-855-5885
Practice Address - Fax:601-855-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3108-991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08324092Medicaid