Healthcare Provider Details

I. General information

NPI: 1225709074
Provider Name (Legal Business Name): SMILE STRAIGHT ORTHODONTICS - JACKSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W WOODROW WILSON AVE STE 400
JACKSON MS
39213-7697
US

IV. Provider business mailing address

310 W WOODROW WILSON AVE STE 400
JACKSON MS
39213-7697
US

V. Phone/Fax

Practice location:
  • Phone: 769-230-1940
  • Fax:
Mailing address:
  • Phone: 601-368-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TERESA LEIGH ZWICKY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 480-866-8811