Healthcare Provider Details

I. General information

NPI: 1801119367
Provider Name (Legal Business Name): MERIDIAN DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 22ND AVE.
MERIDIAN MS
39301-2046
US

IV. Provider business mailing address

1411 22ND AVE.
MERIDIAN MS
39301-2046
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-5701
  • Fax: 601-483-8401
Mailing address:
  • Phone: 601-482-5701
  • Fax: 601-483-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1841
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT S JUSTUS
Title or Position: OWNER
Credential: DDS
Phone: 601-482-5701