Provider Demographics
NPI:1790801298
Name:CATHERINE JOHNSON MINCY, DDS
Entity Type:Organization
Organization Name:CATHERINE JOHNSON MINCY, DDS
Other - Org Name:CATHERINE JOHNSON MINCY, DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:MINCY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-728-8133
Mailing Address - Street 1:607 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2647
Mailing Address - Country:US
Mailing Address - Phone:662-728-8133
Mailing Address - Fax:662-728-6903
Practice Address - Street 1:607 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2647
Practice Address - Country:US
Practice Address - Phone:662-728-8133
Practice Address - Fax:662-728-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3009-971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660215Medicaid