Provider Demographics
NPI:1659539351
Name:MEDICAL ARTS DENTAL GROUP P.A.
Entity Type:Organization
Organization Name:MEDICAL ARTS DENTAL GROUP P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JERRY
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-948-2073
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-948-2073
Mailing Address - Fax:601-354-8773
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-948-2073
Practice Address - Fax:601-354-8773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2288861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty