Provider Demographics
NPI:1316530736
Name:CHICKASAW FAMILY DENTAL
Entity type:Organization
Organization Name:CHICKASAW FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LANTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:457 N CRAFT HWY
Mailing Address - Street 2:
Mailing Address - City:CHICKASAW
Mailing Address - State:AL
Mailing Address - Zip Code:36611-1364
Mailing Address - Country:US
Mailing Address - Phone:251-456-8406
Mailing Address - Fax:
Practice Address - Street 1:457 N CRAFT HWY
Practice Address - Street 2:
Practice Address - City:CHICKASAW
Practice Address - State:AL
Practice Address - Zip Code:36611-1364
Practice Address - Country:US
Practice Address - Phone:251-456-8406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental