Provider Demographics
NPI:1043068125
Name:LD-STARKVILLE
Entity type:Organization
Organization Name:LD-STARKVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIZZ
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAIGNEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-783-9468
Mailing Address - Street 1:407 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2915
Mailing Address - Country:US
Mailing Address - Phone:256-783-9468
Mailing Address - Fax:662-323-1144
Practice Address - Street 1:407 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2915
Practice Address - Country:US
Practice Address - Phone:662-323-2683
Practice Address - Fax:662-323-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty