Provider Demographics
NPI:1598995755
Name:NORTH MS COMMUNITY DENTAL CLINIC
Entity Type:Organization
Organization Name:NORTH MS COMMUNITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-561-1045
Mailing Address - Street 1:PO BOX 13409
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3409
Mailing Address - Country:US
Mailing Address - Phone:662-561-1045
Mailing Address - Fax:662-561-1181
Practice Address - Street 1:560 HIGHWAY 6 E
Practice Address - Street 2:EAST OAKS SHOPPING CENTER
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-3002
Practice Address - Country:US
Practice Address - Phone:662-561-1045
Practice Address - Fax:662-561-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2650-911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660095Medicaid
MS04581039Medicaid