Provider Demographics
NPI:1356606511
Name:MERIDIAN PEDIATRIC DENTAL GROUP, LLC
Entity type:Organization
Organization Name:MERIDIAN PEDIATRIC DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:WILKERSON
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-482-8986
Mailing Address - Street 1:1922 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301
Mailing Address - Country:US
Mailing Address - Phone:601-482-8986
Mailing Address - Fax:601-482-6100
Practice Address - Street 1:1922 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:601-482-8986
Practice Address - Fax:601-482-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060313Medicaid
MS01035561OtherSWE