Provider Demographics
NPI:1427314392
Name:FOREST DENTAL PRACTICE PLLC
Entity type:Organization
Organization Name:FOREST DENTAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-469-3851
Mailing Address - Street 1:PO DRAWER 30
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074
Mailing Address - Country:US
Mailing Address - Phone:601-469-3851
Mailing Address - Fax:
Practice Address - Street 1:1040 HIGHWAY 35 S
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-9423
Practice Address - Country:US
Practice Address - Phone:601-469-3851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21821223G0001X
MS32181223G0001X
MS18531223G0001X
MS10211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty