Provider Demographics
NPI:1598374191
Name:JOE, KAMREN ALESE (DDS)
Entity Type:Individual
Prefix:
First Name:KAMREN
Middle Name:ALESE
Last Name:JOE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7950
Mailing Address - Country:US
Mailing Address - Phone:662-874-5917
Mailing Address - Fax:662-874-5998
Practice Address - Street 1:4824 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7950
Practice Address - Country:US
Practice Address - Phone:662-874-5917
Practice Address - Fax:662-874-5998
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4150-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice