Provider Demographics
NPI:1609960749
Name:MAXILLOFACIAL SURGERY CENTER OF CENTRAL MISSISSIPPI
Entity Type:Organization
Organization Name:MAXILLOFACIAL SURGERY CENTER OF CENTRAL MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:DRUMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:601-420-3223
Mailing Address - Street 1:266 KATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8801
Mailing Address - Country:US
Mailing Address - Phone:601-420-3223
Mailing Address - Fax:601-420-3054
Practice Address - Street 1:266 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-8801
Practice Address - Country:US
Practice Address - Phone:601-420-3223
Practice Address - Fax:601-420-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3119.001223S0112X
MS2820.941223S0112X
MS05.339.00174400000X
MS05.340.00174400000X
MS16843174400000X
MS16896174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123548Medicaid
MS00123549Medicaid
MS00123548Medicaid
MS00123549Medicaid