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General NPI Number Information
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NPI Number | 1922203306
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Entity Type | Organization
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Legal Business Name | BROOKHAVEN SMILE CENTER, INC
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Dates
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Enumeration Date | 06/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1381 JOHNNY JOHNSON DR
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City | BROOKHAVEN
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State | MS
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Zip | 39601-9641
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Country | US
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Telephone | 601-823-2990
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Fax | 601-823-2991
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Provider Business Mailing Address
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Address Line | 1381 JOHNNY JOHNSON DR
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City | BROOKHAVEN
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State | MS
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Zip | 39601-9641
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Country | US
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Telephone | 601-823-2990
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Fax | 601-823-2991
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEREMY DREW KING
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Credential | DMD
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Telephone | 601-823-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 339006
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License Number State | MS
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