Healthcare Provider Details

I. General information

NPI: 1467940627
Provider Name (Legal Business Name): LD-COLUMBUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 LEIGH DR
COLUMBUS MS
39705-3036
US

IV. Provider business mailing address

611 LEIGH DR
COLUMBUS MS
39705-3036
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-1825
  • Fax: 662-657-1012
Mailing address:
  • Phone: 662-328-1825
  • Fax: 662-657-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN S DAIGNEAULT
Title or Position: ADMIN DIRECTOR
Credential: BA, MA
Phone: 256-783-9468