Provider Demographics
NPI:1619579349
Name:CHILDREN'S DENTAL CLINIC, PA
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRICE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SUMNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-844-3315
Mailing Address - Street 1:1555 MEDICAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6580
Mailing Address - Country:US
Mailing Address - Phone:662-844-3315
Mailing Address - Fax:662-842-8228
Practice Address - Street 1:1555 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6580
Practice Address - Country:US
Practice Address - Phone:662-844-3315
Practice Address - Fax:662-842-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660366Medicaid