Provider Demographics
NPI:1316458136
Name:RESERVOIR SMILES DENTISTRY, PLLC
Entity type:Organization
Organization Name:RESERVOIR SMILES DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMYE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHAMBURGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:769-798-3909
Mailing Address - Street 1:1149 OLD FANNIN RD STE 26
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-9244
Mailing Address - Country:US
Mailing Address - Phone:601-992-7972
Mailing Address - Fax:601-992-7975
Practice Address - Street 1:1149 OLD FANNIN RD STE 26
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-9244
Practice Address - Country:US
Practice Address - Phone:601-992-7972
Practice Address - Fax:601-992-7975
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HALL FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3421261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1376725754OtherDR. AMYE L SHAMBURGER