Provider Demographics
NPI:1316306988
Name:BACK BAY FAMILY DENTISTRY
Entity type:Organization
Organization Name:BACK BAY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-392-0509
Mailing Address - Street 1:10409 BONEY AVE
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-4813
Mailing Address - Country:US
Mailing Address - Phone:228-392-0509
Mailing Address - Fax:228-392-8709
Practice Address - Street 1:10409 BONEY AVE
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-4813
Practice Address - Country:US
Practice Address - Phone:228-392-0509
Practice Address - Fax:228-392-8709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3553-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09424204Medicaid