Individual
DR. LENORA G. BALTHIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
D.M.D.
Contact information
Practice address
201 GARDEN CV, RIDGELAND, MS 39157-3555
(601) 832-0542
(601) 605-1966
Mailing address
6771 S SIWELL RD STE C, JACKSON, MS 39272-9697
(601) 373-4500
(601) 373-4503
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2393-88
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00660016
—
MS
01
—
2393-88
DENTAL LICENSE NUMBER
MS
01
—
64-0816017
TAX IDENTIFICATION NUMBER
MS
01
—
856340
UNITED CONCORDIA PROVIDER
—
Enumeration date
10/19/2006
Last updated
07/09/2007
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