Provider Demographics
NPI:1689738833
Name:UNION DENTISTRY, INC.
Entity Type:Organization
Organization Name:UNION DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERDENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-774-9949
Mailing Address - Street 1:25043 HIGHWAY 15
Mailing Address - Street 2:P.O. BOX 276
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-8577
Mailing Address - Country:US
Mailing Address - Phone:601-774-9949
Mailing Address - Fax:601-774-9955
Practice Address - Street 1:25043 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-8577
Practice Address - Country:US
Practice Address - Phone:601-774-9949
Practice Address - Fax:601-774-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3001-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660263Medicaid