Provider Demographics
NPI:1548482862
Name:TUPELO DENTAL GROUP
Entity type:Organization
Organization Name:TUPELO DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:LOWRY
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-844-7231
Mailing Address - Street 1:105 PARK GATE DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3010
Mailing Address - Country:US
Mailing Address - Phone:662-844-7231
Mailing Address - Fax:662-844-0142
Practice Address - Street 1:105 PARK GATE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3010
Practice Address - Country:US
Practice Address - Phone:662-844-7231
Practice Address - Fax:662-844-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty