Provider Demographics
NPI:1689896250
Name:SOUTHERN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SOUTHERN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-373-4500
Mailing Address - Street 1:115 BRIDGETON PLZ
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8711
Mailing Address - Country:US
Mailing Address - Phone:601-373-4500
Mailing Address - Fax:601-373-4503
Practice Address - Street 1:115 BRIDGETON PLZ
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8711
Practice Address - Country:US
Practice Address - Phone:601-373-4500
Practice Address - Fax:601-373-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty