| Organization Name: | CRYSTAL SPRINGS DENTAL CENTER, LLC |
| NPI Number: | 1023386372 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TERRANCE L WARE (OWNER/OPERATOR) |
| Mailing Address: | 304 Harmony Rd Crystal Springs |
| State: | MS US |
| Postal Code: | 390592809 |
| Phone Number: | 9012825706 |
| Fax Number: | |
| NPI Enumeration Date: | 12/01/2011 |
| NPI Last Update Date: | 12/06/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 3439-07 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |