Provider Demographics
NPI:1902120199
Name:CRONIN FAMILY DENTISTRY, P.A.
Entity type:Organization
Organization Name:CRONIN FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:CRONIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-450-5550
Mailing Address - Street 1:5128 OLD HIGHWAY 11
Mailing Address - Street 2:SUITE #7
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6233
Mailing Address - Country:US
Mailing Address - Phone:601-450-5550
Mailing Address - Fax:601-450-5551
Practice Address - Street 1:5128 OLD HIGHWAY 11
Practice Address - Street 2:SUITE #7
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6233
Practice Address - Country:US
Practice Address - Phone:601-450-5550
Practice Address - Fax:601-450-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3348051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01571567Medicaid
MS02334274Medicaid