Provider Demographics
NPI:1518093962
Name:DE SOTO SMILES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:DE SOTO SMILES FAMILY DENTISTRY
Other - Org Name:CHARLES E. HARBISON DDS, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:KAKALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-943-2351
Mailing Address - Street 1:730 GOODMAN ROAD EAST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-2351
Mailing Address - Fax:662-349-2416
Practice Address - Street 1:730 GOODMAN ROAD EAST
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-2351
Practice Address - Fax:662-349-2416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty