Provider Demographics
NPI:1821137316
Name:DENTAL CARE OF MADISON
Entity Type:Organization
Organization Name:DENTAL CARE OF MADISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GRISSOM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-898-9390
Mailing Address - Street 1:1896 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7676
Mailing Address - Country:US
Mailing Address - Phone:601-898-9390
Mailing Address - Fax:601-898-9395
Practice Address - Street 1:1896 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7676
Practice Address - Country:US
Practice Address - Phone:601-898-9390
Practice Address - Fax:601-898-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3218-021223G0001X
MS3228-021223G0001X
MS3260-031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty