Provider Demographics
NPI:1821960683
Name:PEDIATRIC DENTISTRY OF GLUCKSTADT
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF GLUCKSTADT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:769-567-1807
Mailing Address - Street 1:154 CALHOUN STATION PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:GLUCKSTADT
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5544
Mailing Address - Country:US
Mailing Address - Phone:769-567-1807
Mailing Address - Fax:769-567-1620
Practice Address - Street 1:154 CALHOUN STATION PKWY STE F
Practice Address - Street 2:
Practice Address - City:GLUCKSTADT
Practice Address - State:MS
Practice Address - Zip Code:39110-5544
Practice Address - Country:US
Practice Address - Phone:769-567-1807
Practice Address - Fax:769-567-1620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental