Healthcare Provider Details

I. General information

NPI: 1417783317
Provider Name (Legal Business Name): BESPOKE AESTHETICS AND PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MONTGOMERY ST STE C
MADISON MS
39110-1119
US

IV. Provider business mailing address

PO BOX 1998
MADISON MS
39130-1998
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-6581
  • Fax:
Mailing address:
  • Phone: 601-987-6581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICA BASS
Title or Position: OWNER
Credential: MD
Phone: 601-987-6581