Provider Demographics
NPI:1578719399
Name:GRENADA DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:GRENADA DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-226-6014
Mailing Address - Street 1:2117 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5400
Mailing Address - Country:US
Mailing Address - Phone:662-226-6014
Mailing Address - Fax:662-226-9986
Practice Address - Street 1:2117 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5400
Practice Address - Country:US
Practice Address - Phone:662-226-6014
Practice Address - Fax:662-226-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1896-801223G0001X
MS1912-801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1467572206OtherBCBS
MS1619018462OtherBCBS