Provider Demographics
NPI:1558443481
Name:BALTHIS, LENORA G (DMD)
Entity Type:Individual
Prefix:DR
First Name:LENORA
Middle Name:G
Last Name:BALTHIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6771 S SIWELL RD STE C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9697
Mailing Address - Country:US
Mailing Address - Phone:601-373-4500
Mailing Address - Fax:601-373-4503
Practice Address - Street 1:201 GARDEN CV
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3555
Practice Address - Country:US
Practice Address - Phone:601-832-0542
Practice Address - Fax:601-605-1966
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2393-88122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2393-88OtherDENTAL LICENSE NUMBER
MS64-0816017OtherTAX IDENTIFICATION NUMBER
856340OtherUNITED CONCORDIA PROVIDER
MS00660016Medicaid