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Organization
MERIDIAN PEDIATRIC DENTAL GROUP, LLC
Active
Organization
MERIDIAN PEDIATRIC DENTAL GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHELLEY WILKERSON ELLIS D.M.D. (PEDIATRIC DENTIST)
(601) 482-8986
Entity
Organization
Contact information
Practice address
1922 23RD AVE, MERIDIAN, MS 39301
(601) 482-8986
(601) 482-6100
Mailing address
1922 23RD AVE, MERIDIAN, MS 39301
(601) 482-8986
(601) 482-6100
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00060313
—
MS
01
—
01035561
SWE
MS
Enumeration date
07/12/2012
Last updated
07/12/2012
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