Provider Demographics
NPI:1750574695
Name:NORTHEAST DENTAL
Entity type:Organization
Organization Name:NORTHEAST DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C. DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-956-4007
Mailing Address - Street 1:865 PEAR ORCHARD ROAD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-956-4007
Mailing Address - Fax:601-956-2901
Practice Address - Street 1:865 PEAR ORCHARD ROAD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-956-4007
Practice Address - Fax:601-956-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty