NPIMap

Organization Active NPI

South Main Dental Clinic, LLC

Doing business as South Main Dental

  • General Practice Dentistry
  • Pontotoc, MS
National Provider Identifier
1043756687
Registry record updated Jan 6, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
2066-84 Issued in MS
Legal business name
SOUTH MAIN DENTAL CLINIC, LLC
Doing business as
South Main Dental
Practice address
209 S Main St
Pontotoc, MS 38863-3319
Phone
(662) 489-7768
Fax
(662) 489-8256
NPI assigned
Jan 6, 2017
Last updated
Jan 6, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. John Thomas Black Jr., D.M.D.NPI 1376632943
Title
Manager
Phone
(662) 489-7768

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X 2066-84 MS Primary

Addresses

Primary practice location

209 S Main St
Pontotoc, MS 38863-3319

Mailing address

209 S Main St
Pontotoc, MS 38863-3319
Phone (662) 489-7768

Other names 1

  • SOUTH MAIN DENTAL Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1483660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1483660800000",
    "number": "1043756687",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "209 S MAIN ST",
            "city": "PONTOTOC",
            "state": "MS",
            "postal_code": "388633319",
            "telephone_number": "662-489-7768",
            "fax_number": "662-489-8256"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "209 S MAIN ST",
            "city": "PONTOTOC",
            "state": "MS",
            "postal_code": "388633319",
            "telephone_number": "662-489-7768",
            "fax_number": "662-489-8256"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH MAIN DENTAL CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-06",
        "last_updated": "2017-01-06",
        "status": "A",
        "authorized_official_last_name": "BLACK",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "THOMAS",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "662-489-7768",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "MS",
            "license": "2066-84",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTH MAIN DENTAL",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pontotoc, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.