Provider Demographics
NPI:1750626321
Name:CLINTON DENTAL CARE, INC.
Entity type:Organization
Organization Name:CLINTON DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARION
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:GRUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-488-4086
Mailing Address - Street 1:736 CLINTON PKWY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-488-4086
Mailing Address - Fax:601-708-4081
Practice Address - Street 1:736 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-488-4086
Practice Address - Fax:601-708-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS328404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty