Provider Demographics
NPI:1760807994
Name:PAUL FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:PAUL FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-746-3491
Mailing Address - Street 1:410 N JERRY CLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-8274
Mailing Address - Country:US
Mailing Address - Phone:662-746-3491
Mailing Address - Fax:662-746-3946
Practice Address - Street 1:410 N JERRY CLOWER BLVD
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-8274
Practice Address - Country:US
Practice Address - Phone:662-746-3491
Practice Address - Fax:662-746-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04271891Medicaid
MS07223267Medicaid