Provider Demographics
NPI:1811150766
Name:SNELL, DEIDRA JANIECE (DMD)
Entity type:Individual
Prefix:DR
First Name:DEIDRA
Middle Name:JANIECE
Last Name:SNELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:DEIDRA
Other - Middle Name:JANIECE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5800 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2667
Mailing Address - Country:US
Mailing Address - Phone:601-398-2934
Mailing Address - Fax:769-216-3311
Practice Address - Street 1:5800 RIDGEWOOD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2667
Practice Address - Country:US
Practice Address - Phone:601-398-2934
Practice Address - Fax:769-216-3311
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS3459-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1811150766Medicaid