Provider Demographics
NPI:1568626489
Name:WARE FAMILY DENTAL
Entity type:Organization
Organization Name:WARE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-226-1865
Mailing Address - Street 1:2376 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-2827
Mailing Address - Country:US
Mailing Address - Phone:662-226-1865
Mailing Address - Fax:662-226-1845
Practice Address - Street 1:2376 SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-2827
Practice Address - Country:US
Practice Address - Phone:662-226-1865
Practice Address - Fax:662-226-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS336906261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09304801Medicaid
MS08557260Medicaid