Healthcare Provider Details

I. General information

NPI: 1053724120
Provider Name (Legal Business Name): SHAMINA KHANUM DENTIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 01/15/2025
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 WEST NORTHSIDE DRIVE
JACKSON MS
39213
US

IV. Provider business mailing address

3502 WEST NORTHSIDE DRIVE, JACKSON HINDS COMPREHENSIVE
TUPELO MS
38801
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax: 601-364-2600
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4090-19
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: