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General NPI Number Information
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NPI Number | 1881279016
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Entity Type | Organization
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Legal Business Name | SPARKLING SMILES PEDIATRIC DENTISTRY, PLLC
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Dates
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Enumeration Date | 03/09/2021
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Last Update Date | 03/09/2021
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Provider Practice Location Address
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Address Line | 949 BROADWAY DR
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City | HATTIESBURG
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State | MS
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Zip | 39401-7534
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Country | US
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Telephone | 601-620-0075
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Fax |
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Provider Business Mailing Address
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Address Line | 4 CLEARWATER PT
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City | PETAL
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State | MS
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Zip | 39465-8649
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Country | US
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Telephone | 443-413-2935
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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. MYEASHA BURGESS
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Credential | DDS
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Telephone | 443-413-2935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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