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General NPI Number Information
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NPI Number | 1699197574
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Entity Type | Organization
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Legal Business Name | THE PEDIATRIC DENTAL STUDIO, LLC
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Dates
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Enumeration Date | 01/13/2014
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Last Update Date | 01/13/2014
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Provider Practice Location Address
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Address Line | 110 METROPLEX BLVD
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City | PEARL
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State | MS
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Zip | 39208-9210
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Country | US
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Telephone | 601-941-6237
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Fax |
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Provider Business Mailing Address
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Address Line | 603 SOUTHERN OAKS DR
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City | FLORENCE
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State | MS
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Zip | 39073-9456
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRICK W ROSE
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Credential | D.M.D.
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Telephone | 601-941-6237
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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 | 3662-12
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 3662-12
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License Number State | MS
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