1134569981 NPI number — CAMILLE SANDIFER, DMD, MSD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134569981 NPI number — CAMILLE SANDIFER, DMD, MSD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMILLE SANDIFER, DMD, MSD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134569981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 I 55 N
Provider Second Line Business Mailing Address:
HIGHLAND VILLAGE #247
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39211-5930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-981-5004
Provider Business Mailing Address Fax Number:
601-981-0501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 I 55 N
Provider Second Line Business Practice Location Address:
HIGHLAND VILLAGE #247
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-981-5004
Provider Business Practice Location Address Fax Number:
601-981-0501
Provider Enumeration Date:
06/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SANDIFER
Authorized Official First Name:
LYNDSEY
Authorized Official Middle Name:
CAMILLE
Authorized Official Title or Position:
PRESIDENT/DOCTOR
Authorized Official Telephone Number:
601-981-5004

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  OR-458-12 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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