Provider Demographics
NPI:1740453240
Name:ROBERTS, LASHUNDA THOMPSON (DMD)
Entity type:Individual
Prefix:
First Name:LASHUNDA
Middle Name:THOMPSON
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LASHUNDA
Other - Middle Name:RENEE'
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0012
Mailing Address - Country:US
Mailing Address - Phone:662-349-1141
Mailing Address - Fax:662-349-6227
Practice Address - Street 1:1305 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9711
Practice Address - Country:US
Practice Address - Phone:662-349-1141
Practice Address - Fax:662-349-6227
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3526-09122300000X
LA58751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09709245Medicaid