Provider Demographics
NPI:1518208834
Name:DEEP SOUTH SMILES
Entity Type:Organization
Organization Name:DEEP SOUTH SMILES
Other - Org Name:SOUTHERN SMILES FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-323-1531
Mailing Address - Street 1:305 CARVER DR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2513
Mailing Address - Country:US
Mailing Address - Phone:662-323-1531
Mailing Address - Fax:662-323-4048
Practice Address - Street 1:305 CARVER DR
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2513
Practice Address - Country:US
Practice Address - Phone:662-323-1531
Practice Address - Fax:662-323-4048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3160-00122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty