Provider Demographics
NPI:1760995963
Name:LD-TUPELO, LLC
Entity Type:Organization
Organization Name:LD-TUPELO, LLC
Other - Org Name:PREMIER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAIGNEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA
Authorized Official - Phone:256-783-9468
Mailing Address - Street 1:1763 CLIFF GOOKIN BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6723
Mailing Address - Country:US
Mailing Address - Phone:662-842-2802
Mailing Address - Fax:866-251-3105
Practice Address - Street 1:1763 CLIFF GOOKIN BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6723
Practice Address - Country:US
Practice Address - Phone:662-842-2802
Practice Address - Fax:866-251-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1023468659Medicaid
MS1427264241Medicaid
MS1588867337Medicaid