Provider Demographics
NPI:1205986809
Name:FAMILY DENTAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:FAMILY DENTAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHARE HOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-453-5536
Mailing Address - Street 1:702 HIGHWAY 82 W STE A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-5069
Mailing Address - Country:US
Mailing Address - Phone:662-453-5536
Mailing Address - Fax:662-453-2324
Practice Address - Street 1:702 HIGHWAY 82 W STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5069
Practice Address - Country:US
Practice Address - Phone:662-453-5536
Practice Address - Fax:662-453-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2302861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060236Medicaid
MS00884251Medicaid
MS01255511Medicaid