Provider Demographics
NPI:1134601156
Name:ESCATAWPA FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:ESCATAWPA FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-392-0509
Mailing Address - Street 1:8016 HIGHWAY 613
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-8200
Mailing Address - Country:US
Mailing Address - Phone:228-474-1314
Mailing Address - Fax:
Practice Address - Street 1:8016 HIGHWAY 613
Practice Address - Street 2:
Practice Address - City:ESCATAWPA
Practice Address - State:MS
Practice Address - Zip Code:39552
Practice Address - Country:US
Practice Address - Phone:228-474-1314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty