Provider Demographics
NPI:1992527287
Name:SOUTHERN SMILE STUDIO
Entity type:Organization
Organization Name:SOUTHERN SMILE STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:MCADAMS
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-594-8607
Mailing Address - Street 1:121 ANCHOR LANE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-594-8607
Mailing Address - Fax:
Practice Address - Street 1:6155 HWY 25
Practice Address - Street 2:SUITE 1A
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047
Practice Address - Country:US
Practice Address - Phone:769-241-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental