Provider Demographics
NPI:1598131294
Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Other - Org Name:PICAYUNE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUP
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:200 NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3933
Mailing Address - Country:US
Mailing Address - Phone:601-798-8207
Mailing Address - Fax:
Practice Address - Street 1:200 NORWOOD ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3933
Practice Address - Country:US
Practice Address - Phone:601-798-8207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty