Provider Demographics
NPI:1023107240
Name:OXFORD DENTAL CLINIC
Entity type:Organization
Organization Name:OXFORD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-234-5222
Mailing Address - Street 1:2155 SOUTH LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2018
Mailing Address - Country:US
Mailing Address - Phone:662-234-5222
Mailing Address - Fax:662-234-5254
Practice Address - Street 1:2155 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5223
Practice Address - Country:US
Practice Address - Phone:662-234-5222
Practice Address - Fax:662-234-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1700-751223G0001X
MS2825-941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0660083Medicaid
MS0064235Medicaid