# MERIDIAN PEDIATRIC DENTAL GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356606511
- **Authorized official:** DR. SHELLEY WILKERSON ELLIS D.M.D. (PEDIATRIC DENTIST)
- **Authorized official phone:** (601) 482-8986

## Contact information

- **Practice address:** 1922 23RD AVE, MERIDIAN, MS 39301
- **Practice address phone:** (601) 482-8986
- **Practice address fax:** (601) 482-6100
- **Mailing address:** 1922 23RD AVE, MERIDIAN, MS 39301
- **Mailing address phone:** (601) 482-8986
- **Mailing address fax:** (601) 482-6100

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | MS | Yes |

## Other

- **Enumeration date:** 07/12/2012
- **Last updated:** 07/12/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00060313 | — | MS |
| 01 | — | 01035561 | SWE | MS |