Provider Demographics
NPI:1194424747
Name:ABRAHAM DENTAL WINONA, PLLC
Entity type:Organization
Organization Name:ABRAHAM DENTAL WINONA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-720-8194
Mailing Address - Street 1:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:CALHOUN CITY
Mailing Address - State:MS
Mailing Address - Zip Code:38916-0676
Mailing Address - Country:US
Mailing Address - Phone:601-720-8194
Mailing Address - Fax:
Practice Address - Street 1:412 TYLER HOLMES DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1522
Practice Address - Country:US
Practice Address - Phone:662-283-4722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2987-97OtherSTATE BOARD