Provider Demographics
NPI:1760818017
Name:MISS-LOU DENTAL LLC
Entity Type:Organization
Organization Name:MISS-LOU DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:IVERSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-757-4561
Mailing Address - Street 1:207 SERIO BLVD
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-2014
Mailing Address - Country:US
Mailing Address - Phone:318-757-4561
Mailing Address - Fax:318-757-4595
Practice Address - Street 1:110 HIGHWAY 61 SOUTH
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:318-757-4561
Practice Address - Fax:318-757-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3678-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1834190Medicaid