Healthcare Provider Details

I. General information

NPI: 1487578597
Provider Name (Legal Business Name): PETAL DENTAL PROPERTIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BEECH LANE
PETAL MS
39465
US

IV. Provider business mailing address

6643 U S HIGHWAY 98
HATTIESBURG MS
39402-8442
US

V. Phone/Fax

Practice location:
  • Phone: 601-336-0336
  • Fax:
Mailing address:
  • Phone: 604-336-0336
  • Fax: 601-336-0633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TINA MYERS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 601-450-6060