Provider Demographics
NPI:1730551508
Name:RIVERSIDE DENTAL CARE PLLC
Entity type:Organization
Organization Name:RIVERSIDE DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ADKISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:228-475-0005
Mailing Address - Street 1:4400 MCINNIS AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-2814
Mailing Address - Country:US
Mailing Address - Phone:228-475-0005
Mailing Address - Fax:228-475-0057
Practice Address - Street 1:4400 MCINNIS AVE
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2814
Practice Address - Country:US
Practice Address - Phone:228-475-0005
Practice Address - Fax:228-475-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty