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General NPI Number Information
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NPI Number | 1508359340
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Entity Type | Organization
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Legal Business Name | LEGENDARY ORTHODONTICS, LLC
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Dates
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Enumeration Date | 06/06/2018
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Last Update Date | 06/06/2018
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Provider Practice Location Address
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Address Line | 3225 AUDUBON DR
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City | LAUREL
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State | MS
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Zip | 39440-1422
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Country | US
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Telephone | 601-778-0367
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Fax | 601-340-3162
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Provider Business Mailing Address
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Address Line | 3225 AUDUBON DR
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City | LAUREL
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State | MS
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Zip | 39440-1422
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Country | US
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Telephone | 601-778-0367
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Fax | 601-340-3162
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEVIN DOUGLAS
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Credential | DDS
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Telephone | 954-600-5027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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