MEDICARE: SMILES ON BROADWAY DENTAL CARE

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	PEDO-483-14	MS

General Provider Information

NPI Number	:	1942608112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES ON BROADWAY DENTAL CARE

Provider Business Mailing Address
First Line	:	5442 WATKINS DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-2034
Country	:	US
Telephone Number	:	601-665-4996
Fax Number	:	601-398-0450

Provider Business Practice Location Address
First Line	:	5442 WATKINS DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-2034
Country	:	US
Telephone Number	:	601-665-4996
Fax Number	:	601-398-0450

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. LAMONICA DAVIS
Credential	:	DMD
Telephone Number	:	601-665-4996

Provider Enumeration Date	:	12/19/2014
Last Update Date	:	12/19/2014

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Practice Location Address:

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1639352784 — MICHELLE J. GIBSON, MD PLLC
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