Provider Demographics
NPI:1871622753
Name:YAZOO CITY DENTAL CLINIC
Entity type:Organization
Organization Name:YAZOO CITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:NEWMAN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-746-1432
Mailing Address - Street 1:1615 EASY STREET
Mailing Address - Street 2:
Mailing Address - City:YAZOO
Mailing Address - State:MS
Mailing Address - Zip Code:39194-2427
Mailing Address - Country:US
Mailing Address - Phone:662-746-1432
Mailing Address - Fax:662-746-5974
Practice Address - Street 1:1615 EASY STREET
Practice Address - Street 2:
Practice Address - City:YAZOO
Practice Address - State:MS
Practice Address - Zip Code:39194-2427
Practice Address - Country:US
Practice Address - Phone:662-746-1432
Practice Address - Fax:662-746-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015614Medicaid