Provider Demographics
NPI:1407203268
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/ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:
Authorized Official - Last Name:LALA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:601-485-2494
Mailing Address - Street 1:1903 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3108
Mailing Address - Country:US
Mailing Address - Phone:601-485-2494
Mailing Address - Fax:601-485-4837
Practice Address - Street 1:1903 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3108
Practice Address - Country:US
Practice Address - Phone:601-485-2494
Practice Address - Fax:601-485-4837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3785-151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty