Provider Demographics
NPI:1245539808
Name:COMMUNITY DENTAL, INC
Entity type:Organization
Organization Name:COMMUNITY DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMAAL
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:LONGINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-825-2150
Mailing Address - Street 1:908 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2973
Mailing Address - Country:US
Mailing Address - Phone:601-825-2150
Mailing Address - Fax:601-825-2792
Practice Address - Street 1:908 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2973
Practice Address - Country:US
Practice Address - Phone:601-825-2150
Practice Address - Fax:601-825-2792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3483-08122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty