Provider Demographics
NPI:1639813454
Name:MISSISSIPPI OROFACIAL PAIN, LLC
Entity Type:Organization
Organization Name:MISSISSIPPI OROFACIAL PAIN, LLC
Other - Org Name:MISSISSIPPI OROFACIAL PAIN
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:769-567-2555
Mailing Address - Street 1:108 S MAPLE ST STE C
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2357
Mailing Address - Country:US
Mailing Address - Phone:697-567-2555
Mailing Address - Fax:769-567-2556
Practice Address - Street 1:108 S MAPLE ST STE C
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2305
Practice Address - Country:US
Practice Address - Phone:601-720-7662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1639813454OtherLOCATION NPI
MS1285640383OtherPROVIDER NPI