=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346102092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE SMILES OCEAN SPRINGS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2025
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2693 BIENVILLE BLVD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-872-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2693 BIENVILLE BLVD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-872-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. ANDREW MARTIN GILICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-872-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------