Provider Demographics
NPI:1649893363
Name:PRESTIGE DENTAL CARE
Entity type:Organization
Organization Name:PRESTIGE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIANTI
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:WOODFORK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-533-0923
Mailing Address - Street 1:7138 S SIWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272
Mailing Address - Country:US
Mailing Address - Phone:601-533-0923
Mailing Address - Fax:601-351-5609
Practice Address - Street 1:7138 S SIWELL ROAD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272
Practice Address - Country:US
Practice Address - Phone:601-533-0923
Practice Address - Fax:601-351-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty