Healthcare Provider Details

I. General information

NPI: 1891842332
Provider Name (Legal Business Name): KIMBERLY BLAIR SMITH DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 MAIN ST N
MENDENHALL MS
39114-3318
US

IV. Provider business mailing address

409 MAIN ST N
MENDENHALL MS
39114-3318
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-1223
  • Fax: 601-847-9131
Mailing address:
  • Phone: 601-847-1223
  • Fax: 601-847-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3186-01
License Number StateMS

VIII. Authorized Official

Name: KIMBERLY BLAIR SMITH
Title or Position: PRESIDENT
Credential: DMD
Phone: 601-847-1223