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General NPI Number Information
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NPI Number | 1932859105
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Entity Type | Individual
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Provider Name | JASMINE MONIQUE MACK DDS
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Gender | Female
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Dates
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Enumeration Date | 03/28/2022
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Last Update Date | 06/13/2023
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Provider Practice Location Address
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Address Line | 34 BRUNSWICK ST
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City | BYHALIA
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State | MS
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Zip | 38611-7000
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Country | US
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Telephone | 662-838-6898
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Fax | 662-838-6903
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Provider Business Mailing Address
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Address Line | 10886 COUNTY ROAD 44
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City | LINDEN
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State | AL
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Zip | 36748-4137
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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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4361-23
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License Number State | MS
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