Provider Demographics
NPI:1831978469
Name:FRIENDS OF MISSISSIPPI DENTISTRY
Entity type:Organization
Organization Name:FRIENDS OF MISSISSIPPI DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SREENIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-456-3712
Mailing Address - Street 1:108 CLAIBORNE CHASE
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-9706
Mailing Address - Country:US
Mailing Address - Phone:619-456-3712
Mailing Address - Fax:
Practice Address - Street 1:105 N BROOKS AVE
Practice Address - Street 2:
Practice Address - City:PELAHATCHIE
Practice Address - State:MS
Practice Address - Zip Code:39145-3091
Practice Address - Country:US
Practice Address - Phone:601-854-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental