Healthcare Provider Details

I. General information

NPI: 1942608112
Provider Name (Legal Business Name): SMILES ON BROADWAY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5442 WATKINS DR
JACKSON MS
39206-2034
US

IV. Provider business mailing address

5442 WATKINS DR
JACKSON MS
39206-2034
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4996
  • Fax: 601-398-0450
Mailing address:
  • Phone: 601-665-4996
  • Fax: 601-398-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberPEDO-483-14
License Number StateMS

VIII. Authorized Official

Name: DR. LAMONICA DAVIS
Title or Position: PEDIATRIC DENTIST
Credential: DMD
Phone: 601-665-4996