Provider Demographics
NPI:1942608112
Name:SMILES ON BROADWAY DENTAL CARE
Entity type:Organization
Organization Name:SMILES ON BROADWAY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAMONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-665-4996
Mailing Address - Street 1:5442 WATKINS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2034
Mailing Address - Country:US
Mailing Address - Phone:601-665-4996
Mailing Address - Fax:601-398-0450
Practice Address - Street 1:5442 WATKINS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2034
Practice Address - Country:US
Practice Address - Phone:601-665-4996
Practice Address - Fax:601-398-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO-483-141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty