Provider Demographics
NPI:1538504824
Name:SOUTH MISSISSIPPI SMILES DENTISTRY LLC
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI SMILES DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
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:520-722-1182
Mailing Address - Street 1:4105 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5312
Mailing Address - Country:US
Mailing Address - Phone:520-722-1182
Mailing Address - Fax:520-798-2418
Practice Address - Street 1:4105 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5312
Practice Address - Country:US
Practice Address - Phone:520-722-1182
Practice Address - Fax:520-798-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3571101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty