Healthcare Provider Details

I. General information

NPI: 1134569981
Provider Name (Legal Business Name): CAMILLE SANDIFER, DMD, MSD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N HIGHLAND VILLAGE #247
JACKSON MS
39211-5930
US

IV. Provider business mailing address

4500 I 55 N HIGHLAND VILLAGE #247
JACKSON MS
39211-5930
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-5004
  • Fax: 601-981-0501
Mailing address:
  • Phone: 601-981-5004
  • Fax: 601-981-0501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberOR-458-12
License Number StateMS

VIII. Authorized Official

Name: DR. LYNDSEY CAMILLE SANDIFER
Title or Position: PRESIDENT/DOCTOR
Credential: DMD, MSD
Phone: 601-981-5004