Provider Demographics
NPI:1265779052
Name:GRANTS FERRY FAMILY DENTISTRY
Entity type:Organization
Organization Name:GRANTS FERRY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-992-1605
Mailing Address - Street 1:1075 LAKE VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6743
Mailing Address - Country:US
Mailing Address - Phone:601-992-1605
Mailing Address - Fax:601-992-9534
Practice Address - Street 1:1075 LAKE VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6743
Practice Address - Country:US
Practice Address - Phone:601-992-1605
Practice Address - Fax:601-992-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3276-03261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental