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General NPI Number Information
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NPI Number | 1295402519
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Entity Type | Organization
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Legal Business Name | ISMILE FAMILY DENTISTRY
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 1305 CHURCH RD E
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9711
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Country | US
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Telephone | 662-349-1141
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Fax | 662-349-6227
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Provider Business Mailing Address
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Address Line | PO BOX 1168
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City | SOUTHAVEN
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State | MS
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Zip | 38671-0012
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Country | US
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Telephone | 662-349-1141
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Fax | 662-349-6227
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LASHUNDA THOMPSON ROBERTS
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Credential | DMD
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Telephone | 601-622-1073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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