Provider Demographics
NPI:1396006631
Name:MISSISSIPPI ENDODONTIC GROUP
Entity Type:Organization
Organization Name:MISSISSIPPI ENDODONTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-420-9322
Mailing Address - Street 1:797 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9351
Mailing Address - Country:US
Mailing Address - Phone:601-420-9322
Mailing Address - Fax:601-420-9363
Practice Address - Street 1:797 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9351
Practice Address - Country:US
Practice Address - Phone:601-420-9322
Practice Address - Fax:601-420-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental