Provider Demographics
NPI:1649425596
Name:LALA, ASIF A (DMD, MD)
Entity type:Individual
Prefix:
First Name:ASIF
Middle Name:A
Last Name:LALA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3926
Mailing Address - Country:US
Mailing Address - Phone:601-485-2494
Mailing Address - Fax:601-485-4837
Practice Address - Street 1:1212 24TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3926
Practice Address - Country:US
Practice Address - Phone:601-485-2494
Practice Address - Fax:601-485-4837
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0144051223S0112X
PADS0369671223S0112X
MS3785-151223S0112X
MS23598204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05034060Medicaid