Provider Demographics
NPI:1578658373
Name:NORTH MISSISSIPPI DENTAL SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI DENTAL SPECIALISTS, PLLC
Other - Org Name:THE CHILDREN'S DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:ARMSTRONG
Authorized Official - Last Name:MUSGRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-893-7337
Mailing Address - Street 1:2925 NAIL RD E STE 103
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6715
Mailing Address - Country:US
Mailing Address - Phone:662-893-7337
Mailing Address - Fax:662-893-7881
Practice Address - Street 1:2925 NAIL RD E STE 103
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6715
Practice Address - Country:US
Practice Address - Phone:662-893-7337
Practice Address - Fax:662-893-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3136-001223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016069Medicaid