Healthcare Provider Details

I. General information

NPI: 1831104793
Provider Name (Legal Business Name): NORTH MISSISSIPPI ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 S MADISON ST
TUPELO MS
38801-6309
US

IV. Provider business mailing address

1043 S MADISON ST
TUPELO MS
38801-6309
US

V. Phone/Fax

Practice location:
  • Phone: 662-842-8200
  • Fax: 662-844-3157
Mailing address:
  • Phone: 662-842-8200
  • Fax: 662-844-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberMS162174
License Number StateMS

VIII. Authorized Official

Name: MRS. KAREN LYNN COSTELLO
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-842-8200