Basic Information
Provider Information
NPI: 1003002320
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EKLUND
FirstName: D.
MiddleName: JASON
NamePrefix:  
NameSuffix:  
Credential: D.M.D. P.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2701 OLD BRANDON RD
Address2:  
City: PEARL
State: MS
PostalCode: 392084702
CountryCode: US
TelephoneNumber: 6019393561
FaxNumber: 6019393583
Practice Location
Address1: 2701 OLD BRANDON RD
Address2:  
City: PEARL
State: MS
PostalCode: 392084702
CountryCode: US
TelephoneNumber: 6019393561
FaxNumber: 6019393583
Other Information
ProviderEnumerationDate: 09/20/2007
LastUpdateDate: 09/20/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X267192MSY Dental ProvidersDentistGeneral Practice

No ID Information.


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