Provider Demographics
NPI:1811620214
Name:MISSISSIPPI DENTAL CENTER OF JACKSON LLC
Entity type:Organization
Organization Name:MISSISSIPPI DENTAL CENTER OF JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARKE
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:STRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-506-9490
Mailing Address - Street 1:4500 I 55 N STE 235
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5931
Mailing Address - Country:US
Mailing Address - Phone:601-987-8722
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 235
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-987-8722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty