Provider Demographics
NPI:1821678566
Name:SENATOBIA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SENATOBIA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-562-9484
Mailing Address - Street 1:102 N ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2149
Mailing Address - Country:US
Mailing Address - Phone:662-562-9484
Mailing Address - Fax:662-301-8222
Practice Address - Street 1:102 N ROBINSON ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2149
Practice Address - Country:US
Practice Address - Phone:662-562-9484
Practice Address - Fax:662-301-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060223Medicaid
MS00834891Medicaid