Provider Demographics
NPI:1912475922
Name:COLUMBIA FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:COLUMBIA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-543-6510
Mailing Address - Street 1:430 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3006
Mailing Address - Country:US
Mailing Address - Phone:601-543-6510
Mailing Address - Fax:
Practice Address - Street 1:430 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3006
Practice Address - Country:US
Practice Address - Phone:601-543-6510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL C HUMPHREYS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08902788Medicaid