MEDICARE: DR. DEIDRA JANIECE SNELL D.M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	3459-08	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	:	1811150766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEIDRA JANIECE SNELL D.M.D.

Provider Business Mailing Address
First Line	:	5800 RIDGEWOOD RD
Second Line	:	SUITE 105
City	:	JACKSON
State	:	MS
Zip	:	39211-2667
Country	:	US
Telephone Number	:	601-398-2934
Fax Number	:	769-216-3311

Provider Business Practice Location Address
First Line	:	5800 RIDGEWOOD RD
Second Line	:	SUITE 105
City	:	JACKSON
State	:	MS
Zip	:	39211-2667
Country	:	US
Telephone Number	:	601-398-2934
Fax Number	:	769-216-3311

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	10/11/2016

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Directions to “ DR. DEIDRA JANIECE SNELL D.M.D.” Practice Location

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