Provider Demographics
NPI:1134212038
Name:CHICKASAW DENTAL GROUP L. L. C.
Entity type:Organization
Organization Name:CHICKASAW DENTAL GROUP L. L. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEENA
Authorized Official - Middle Name:FREEMAN
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-456-9992
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851
Mailing Address - Country:US
Mailing Address - Phone:662-456-9992
Mailing Address - Fax:662-456-9093
Practice Address - Street 1:327 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851
Practice Address - Country:US
Practice Address - Phone:662-456-9992
Practice Address - Fax:662-456-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016032Medicaid