Provider Demographics
NPI:1740768332
Name:BACKSTROM, MILES
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:
Last Name:BACKSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-8901
Mailing Address - Country:US
Mailing Address - Phone:662-397-3749
Mailing Address - Fax:
Practice Address - Street 1:2690 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-6941
Practice Address - Country:US
Practice Address - Phone:662-869-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3990-181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice