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General NPI Number Information
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NPI Number | 1851640437
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Entity Type | Organization
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Legal Business Name | MS PERIODONTIC SPECIALISTS GROUP, PLLC
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Dates
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Enumeration Date | 08/29/2012
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Last Update Date | 08/12/2014
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Provider Practice Location Address
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Address Line | 209 WOODLINE DR.
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City | FLOWOOD
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State | MS
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Zip | 39232
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Country | US
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Telephone | 601-664-2600
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Fax | 601-664-2650
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Provider Business Mailing Address
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Address Line | 209 WOODLINE DR.
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City | FLOWOOD
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State | MS
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Zip | 39232
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Country | US
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Telephone | 601-664-2600
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Fax | 601-664-2650
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAMUEL REID LESTER
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Credential | DMD
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Telephone | 601-664-2600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 45012
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License Number State | MS
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