Provider Demographics
NPI:1639235963
Name:DORMOIS & FUSON, P.L.L.C.
Entity Type:Organization
Organization Name:DORMOIS & FUSON, P.L.L.C.
Other - Org Name:PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFC MGR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ORFANS
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:662-349-3838
Mailing Address - Street 1:7734 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5306
Mailing Address - Country:US
Mailing Address - Phone:662-349-3838
Mailing Address - Fax:662-349-5923
Practice Address - Street 1:7734 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5306
Practice Address - Country:US
Practice Address - Phone:662-349-3838
Practice Address - Fax:662-349-5923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty