Provider Demographics
NPI:1851886857
Name:GRENADA DENTAL CLINIC PLLC
Entity Type:Organization
Organization Name:GRENADA DENTAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAN GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-226-1757
Mailing Address - Street 1:1800 HILL DR STE A
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5071
Mailing Address - Country:US
Mailing Address - Phone:662-226-1757
Mailing Address - Fax:662-307-2709
Practice Address - Street 1:1800 HILL DR STE A
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5071
Practice Address - Country:US
Practice Address - Phone:662-226-1757
Practice Address - Fax:662-307-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3934-17261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental