Provider Demographics
NPI:1730839622
Name:WEST MAIN DENTAL
Entity type:Organization
Organization Name:WEST MAIN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:ENGLISH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-559-5529
Mailing Address - Street 1:PO BOX 477
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-0477
Mailing Address - Country:US
Mailing Address - Phone:601-559-5529
Mailing Address - Fax:
Practice Address - Street 1:450 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-8165
Practice Address - Country:US
Practice Address - Phone:601-857-5021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental