Provider Demographics
NPI:1104151265
Name:HUMPHREYS DENTAL, LLC
Entity type:Organization
Organization Name:HUMPHREYS DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHANDLER
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-794-8115
Mailing Address - Street 1:444 SHELBY SPEIGHTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475
Mailing Address - Country:US
Mailing Address - Phone:601-794-8115
Mailing Address - Fax:601-794-8115
Practice Address - Street 1:444 SHELBY SPEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475
Practice Address - Country:US
Practice Address - Phone:601-794-8115
Practice Address - Fax:601-794-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3329-051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty