Provider Demographics
NPI:1568672293
Name:SELVIDGE, LEROY ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:ALLEN
Last Name:SELVIDGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 MIMOSA DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5102
Mailing Address - Country:US
Mailing Address - Phone:662-234-0922
Mailing Address - Fax:662-234-0888
Practice Address - Street 1:1108 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5102
Practice Address - Country:US
Practice Address - Phone:662-234-0922
Practice Address - Fax:662-234-0888
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1767-771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice