Provider Demographics
NPI:1982726824
Name:LUMBERTON DENTAL CLINIC PA
Entity Type:Organization
Organization Name:LUMBERTON DENTAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:VANN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-796-8449
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:MS
Mailing Address - Zip Code:39455
Mailing Address - Country:US
Mailing Address - Phone:601-796-8449
Mailing Address - Fax:601-796-9225
Practice Address - Street 1:7935 US HWY 11
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455
Practice Address - Country:US
Practice Address - Phone:601-796-8449
Practice Address - Fax:601-796-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS173676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064465Medicaid