Provider Demographics
NPI:1841808904
Name:CHILDRESS, SARAH ELIZABETH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3512
Mailing Address - Country:US
Mailing Address - Phone:903-491-6456
Mailing Address - Fax:
Practice Address - Street 1:2574 MARCIA CT STE A
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2341
Practice Address - Country:US
Practice Address - Phone:228-388-9545
Practice Address - Fax:228-385-1161
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4604-20DH124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist