Provider Demographics
NPI:1881073716
Name:BOONEVILLE GENERAL DENTISTRY, P.A.
Entity type:Organization
Organization Name:BOONEVILLE GENERAL DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-728-2123
Mailing Address - Street 1:507 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3709
Mailing Address - Country:US
Mailing Address - Phone:662-728-2123
Mailing Address - Fax:662-728-1748
Practice Address - Street 1:507 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3709
Practice Address - Country:US
Practice Address - Phone:662-728-2123
Practice Address - Fax:662-728-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3645 121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09234892Medicaid