Provider Demographics
NPI:1558119339
Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:THULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:9035 E SANDIDGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9035 E SANDIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3563
Practice Address - Country:US
Practice Address - Phone:662-895-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF MISSISSIPPI, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty