Healthcare Provider Details

I. General information

NPI: 1548273576
Provider Name (Legal Business Name): LUBNA FAWAD D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6100
  • Fax: 601-984-6103
Mailing address:
  • Phone: 601-984-6100
  • Fax: 601-984-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3351-05
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: