MEDICARE: PEDIATRIC DENTISTRY, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	1865-80	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134414733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY, P.A.

Provider Business Mailing Address
First Line	:	5315 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-922-0066
Fax Number	:	601-922-0077

Provider Business Practice Location Address
First Line	:	5315 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-922-0066
Fax Number	:	601-922-0077

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. L LEE COPE
Credential	:	D.D.S.
Telephone Number	:	601-922-0066

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/13/2011

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