Provider Demographics
NPI:1417366725
Name:PEARL RIVER DENTAL, PLLC
Entity type:Organization
Organization Name:PEARL RIVER DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOUPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:209 RIVERWIND EAST DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208
Mailing Address - Country:US
Mailing Address - Phone:601-936-6161
Mailing Address - Fax:603-936-6163
Practice Address - Street 1:209 RIVERWIND EAST DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-936-6161
Practice Address - Fax:601-936-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940-96122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty