Provider Demographics
NPI:1912077082
Name:CALLAWAY ORTHODONTICS
Entity Type:Organization
Organization Name:CALLAWAY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COOPER
Authorized Official - Middle Name:E
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:662-615-4225
Mailing Address - Street 1:100 STARR AVE
Mailing Address - Street 2:STE D
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:662-615-4225
Mailing Address - Fax:662-615-4288
Practice Address - Street 1:100 STARR AVE
Practice Address - Street 2:STE D
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-615-4225
Practice Address - Fax:662-615-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2991971223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
49117OtherUNITED CONCORDIA