Provider Demographics
NPI:1861816670
Name:MID TOWN DENTAL
Entity Type:Organization
Organization Name:MID TOWN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-355-5275
Mailing Address - Street 1:808 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2602
Mailing Address - Country:US
Mailing Address - Phone:601-355-5275
Mailing Address - Fax:
Practice Address - Street 1:808 N STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2602
Practice Address - Country:US
Practice Address - Phone:601-355-5275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty