Provider Demographics
NPI:1063667129
Name:THE SMILE CENTER OF CLARKSDALE
Entity Type:Organization
Organization Name:THE SMILE CENTER OF CLARKSDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:PRESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:662-226-1865
Mailing Address - Street 1:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1199
Mailing Address - Country:US
Mailing Address - Phone:662-226-1865
Mailing Address - Fax:
Practice Address - Street 1:526 CHOCTAW STREET
Practice Address - Street 2:SUITES B & C
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-226-1865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS336906261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental