Provider Demographics
NPI:1699197574
Name:THE PEDIATRIC DENTAL STUDIO, LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC DENTAL STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-941-6237
Mailing Address - Street 1:603 SOUTHERN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-9456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 METROPLEX BLVD
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9210
Practice Address - Country:US
Practice Address - Phone:601-941-6237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3662-121223P0221X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty