Provider Demographics
NPI:1932499241
Name:GREENVILLE DENTAL CLINIC
Entity Type:Organization
Organization Name:GREENVILLE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUSTACE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WINN
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-332-9011
Mailing Address - Street 1:1391 E REED RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7234
Mailing Address - Country:US
Mailing Address - Phone:662-332-9011
Mailing Address - Fax:662-332-9012
Practice Address - Street 1:1391 E REED RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7234
Practice Address - Country:US
Practice Address - Phone:662-332-9011
Practice Address - Fax:662-332-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2893-951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660177Medicaid