Provider Demographics
NPI:1962831719
Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Other - Org Name:MY VICKSBURG DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED. SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:1805 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3709
Mailing Address - Country:US
Mailing Address - Phone:601-638-2361
Mailing Address - Fax:601-634-0864
Practice Address - Street 1:1805 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3709
Practice Address - Country:US
Practice Address - Phone:601-638-2361
Practice Address - Fax:601-634-0864
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty