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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