Provider Demographics
NPI:1528280880
Name:KELLUM DENTAL CLINIC
Entity type:Organization
Organization Name:KELLUM DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNDI
Authorized Official - Middle Name:B
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-842-5080
Mailing Address - Street 1:PO BOX 1486
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-1486
Mailing Address - Country:US
Mailing Address - Phone:662-842-5080
Mailing Address - Fax:662-842-5896
Practice Address - Street 1:505 ROBINS ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3715
Practice Address - Country:US
Practice Address - Phone:662-842-5080
Practice Address - Fax:662-842-5896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2554-90261QD0000X
MS1782-77261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental