Provider Demographics
NPI:1235508342
Name:EAST MISSISSIPPI ORAL & FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:EAST MISSISSIPPI ORAL & FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:A
Authorized Official - Last Name:LALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:912-675-8468
Mailing Address - Street 1:1212 24TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301
Mailing Address - Country:US
Mailing Address - Phone:601-286-5240
Mailing Address - Fax:
Practice Address - Street 1:1212 24TH AVENUE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-286-5240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3785-15261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery