Provider Demographics
NPI:1871168567
Name:MISSISSIPPI PROSTHETIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:MISSISSIPPI PROSTHETIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MILNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-473-3578
Mailing Address - Street 1:4500 I 55 N STE 266
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 266
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5932
Practice Address - Country:US
Practice Address - Phone:601-473-3578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental