Healthcare Provider Details

I. General information

NPI: 1336346113
Provider Name (Legal Business Name): WAVELAND DENTAL CENTERPLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 AUDERER BLVD
WAVELAND MS
39576-2432
US

IV. Provider business mailing address

110 AUDERER BLVD
WAVELAND MS
39576-2432
US

V. Phone/Fax

Practice location:
  • Phone: 228-270-0044
  • Fax: 228-270-0047
Mailing address:
  • Phone: 228-270-0044
  • Fax: 228-270-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANA HAL JONES
Title or Position: OWNER DENTIST
Credential: D.M.D.
Phone: 228-270-0044