Provider Demographics
NPI:1699358739
Name:HERITAGE FAMILY DENTAL
Entity Type:Organization
Organization Name:HERITAGE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:303 S ARCHUSA AVE # A
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-2325
Mailing Address - Country:US
Mailing Address - Phone:601-776-6630
Mailing Address - Fax:
Practice Address - Street 1:303 S ARCHUSA AVE # A
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2325
Practice Address - Country:US
Practice Address - Phone:601-776-6630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental