Provider Demographics
NPI:1316035207
Name:FIRST DENTAL, PA
Entity type:Organization
Organization Name:FIRST DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-264-5100
Mailing Address - Street 1:PO BOX 17798
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-7798
Mailing Address - Country:US
Mailing Address - Phone:601-264-5100
Mailing Address - Fax:601-264-6669
Practice Address - Street 1:313 S 40TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1734
Practice Address - Country:US
Practice Address - Phone:601-264-5100
Practice Address - Fax:601-264-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1453-711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty