Healthcare Provider Details

I. General information

NPI: 1639813454
Provider Name (Legal Business Name): MISSISSIPPI OROFACIAL PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAPLE ST STE C
RIDGELAND MS
39157-2305
US

IV. Provider business mailing address

108 S MAPLE ST STE C
RIDGELAND MS
39157-2357
US

V. Phone/Fax

Practice location:
  • Phone: 601-720-7662
  • Fax:
Mailing address:
  • Phone: 697-567-2555
  • Fax: 769-567-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAUL COLEMAN RILEY
Title or Position: AUTHORIZED OFFICIAL
Credential: D.D.S.
Phone: 769-567-2555