Provider Demographics
NPI:1306086954
Name:DREAM TEAM FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:DREAM TEAM FAMILY DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:SIFFRARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-470-4621
Mailing Address - Street 1:6760 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7056
Mailing Address - Country:US
Mailing Address - Phone:662-470-4621
Mailing Address - Fax:662-470-4621
Practice Address - Street 1:6760 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-470-4621
Practice Address - Fax:662-470-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3489-08122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty