Provider Demographics
NPI:1871915397
Name:CENTRAL MISSISSIPPI OUTREACH, LLC
Entity type:Organization
Organization Name:CENTRAL MISSISSIPPI OUTREACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAUPTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-214-3041
Mailing Address - Street 1:2160 D NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MS
Mailing Address - Zip Code:39175-9039
Mailing Address - Country:US
Mailing Address - Phone:601-214-3041
Mailing Address - Fax:
Practice Address - Street 1:2160 D NEWMAN RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MS
Practice Address - Zip Code:39175-9039
Practice Address - Country:US
Practice Address - Phone:601-214-3041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3581-11122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty