Organization
BACK BAY FAMILY DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEREMY W PARKER D.M.D. (OWNER)
(228) 392-0509
Entity
Organization
Contact information
Practice address
10409 BONEY AVE, DIBERVILLE, MS 39540-4813
(228) 392-0509
(228) 392-8709
Mailing address
10409 BONEY AVE, DIBERVILLE, MS 39540-4813
(228) 392-0509
(228) 392-8709
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
3553-10
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09424204
—
MS
Enumeration date
02/11/2016
Last updated
02/11/2016
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