Provider Demographics
NPI:1851640437
Name:MS PERIODONTIC SPECIALISTS GROUP, PLLC
Entity Type:Organization
Organization Name:MS PERIODONTIC SPECIALISTS GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:REID
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-664-2600
Mailing Address - Street 1:209 WOODLINE DR.
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-664-2600
Mailing Address - Fax:601-664-2650
Practice Address - Street 1:209 WOODLINE DR.
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-664-2600
Practice Address - Fax:601-664-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS450121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty