MEDICARE: SMILE MISSION MISSISSIPPI LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952294837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE MISSION MISSISSIPPI LLC

Provider Business Mailing Address
First Line	:	9900 SW 168TH ST STE 1
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33157-4378
Country	:	US
Telephone Number	:	786-701-8246
Fax Number	:

Provider Business Practice Location Address
First Line	:	1836 CRANE RIDGE DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4901
Country	:	US
Telephone Number	:	786-701-8246
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DUSTIN PFUNDHELLER
Credential	:
Telephone Number	:	786-701-8246

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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Directions to “SMILE MISSION MISSISSIPPI LLC ” Practice Location

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