Provider Demographics
NPI:1972908622
Name:PETAL FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PETAL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-584-9481
Mailing Address - Street 1:139 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2331
Mailing Address - Country:US
Mailing Address - Phone:601-584-9481
Mailing Address - Fax:601-544-5161
Practice Address - Street 1:139 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2331
Practice Address - Country:US
Practice Address - Phone:601-584-9481
Practice Address - Fax:601-544-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty