Provider Demographics
NPI:1295402519
Name:ISMILE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ISMILE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LASHUNDA
Authorized Official - Middle Name:THOMPSON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-622-1073
Mailing Address - Street 1:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0012
Mailing Address - Country:US
Mailing Address - Phone:662-349-1141
Mailing Address - Fax:662-349-6227
Practice Address - Street 1:1305 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9711
Practice Address - Country:US
Practice Address - Phone:662-349-1141
Practice Address - Fax:662-349-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09709245Medicaid