Provider Demographics
NPI:1306142674
Name:POPLARVILLE DENTAL CLINIC
Entity type:Organization
Organization Name:POPLARVILLE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-795-8024
Mailing Address - Street 1:1718 S MAIN ST
Mailing Address - Street 2:MAILING P O BOX 73
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-4287
Mailing Address - Country:US
Mailing Address - Phone:601-795-8024
Mailing Address - Fax:601-795-0745
Practice Address - Street 1:1718 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-4287
Practice Address - Country:US
Practice Address - Phone:601-795-8024
Practice Address - Fax:601-795-0745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3142-00261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660344Medicaid