Provider Demographics
NPI:1790855666
Name:LITTLE, REUBEN ROY II (DDS)
Entity Type:Individual
Prefix:DR
First Name:REUBEN
Middle Name:ROY
Last Name:LITTLE
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-3843
Mailing Address - Country:US
Mailing Address - Phone:601-693-5961
Mailing Address - Fax:601-486-2631
Practice Address - Street 1:519 BONITA LAKES DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6970
Practice Address - Country:US
Practice Address - Phone:601-485-2095
Practice Address - Fax:601-486-2631
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3204-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660407Medicaid