MEDICARE: SOUTHERN FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		MS

General Provider Information

NPI Number	:	1689896250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	115 BRIDGETON PLZ
Second Line	:
City	:	BYRAM
State	:	MS
Zip	:	39272-8711
Country	:	US
Telephone Number	:	601-373-4500
Fax Number	:	601-373-4503

Provider Business Practice Location Address
First Line	:	115 BRIDGETON PLZ
Second Line	:
City	:	BYRAM
State	:	MS
Zip	:	39272-8711
Country	:	US
Telephone Number	:	601-373-4500
Fax Number	:	601-373-4503

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. AIMEE KELLY
Credential	:	DMD
Telephone Number	:	601-373-4500

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/21/2022

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Directions to “SOUTHERN FAMILY DENTISTRY ” Practice Location

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