Provider Demographics
NPI:1346782893
Name:MISSISSIPPI SMILES DENTISTRY LLC
Entity Type:Organization
Organization Name:MISSISSIPPI SMILES DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:520-227-0711
Mailing Address - Street 1:310 W WOODROW WILSON AVE
Mailing Address - Street 2:400
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:769-230-1940
Mailing Address - Fax:601-292-6311
Practice Address - Street 1:310 W WOODROW WILSON AVE
Practice Address - Street 2:400
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:769-230-1940
Practice Address - Fax:601-292-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3571101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty