Provider Demographics
NPI:1871734715
Name:GROWING SMILES OF PICAYUNE, PLLC
Entity type:Organization
Organization Name:GROWING SMILES OF PICAYUNE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:E
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-798-0500
Mailing Address - Street 1:500 GOODYEAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3217
Mailing Address - Country:US
Mailing Address - Phone:601-798-0500
Mailing Address - Fax:
Practice Address - Street 1:318 MEMORIAL BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5509
Practice Address - Country:US
Practice Address - Phone:601-798-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3213-021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty