MEDICARE: LD-RIDGELAND, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1427762111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LD-RIDGELAND, LLC

Provider Business Mailing Address
First Line	:	772 LAKE HARBOUR DR STE 2
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4365
Country	:	US
Telephone Number	:	601-607-7876
Fax Number	:	601-607-7878

Provider Business Practice Location Address
First Line	:	722 LAKE HARBOUR DR STE 2
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4354
Country	:	US
Telephone Number	:	601-607-7876
Fax Number	:	601-607-7878

Authorized Official
Title or Position	:	ADMIN DIRECTOR
Name	:	LAUREN S DAIGNEAULT
Credential	:	BA, MA
Telephone Number	:	256-783-9468

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	07/07/2023

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