1043557085 NPI number — MAIN STREET DENTAL

Table of content: (NPI 1043557085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043557085 NPI number — MAIN STREET DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET DENTAL
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:
DRS. JOE BRADDY & SIMMONS
Provider Other Organization Name Type Code:
4
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:
1043557085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8747 NORTHWEST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-2409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-393-0781
Provider Business Mailing Address Fax Number:
662-342-0750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8747 NORTHWEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-393-0781
Provider Business Practice Location Address Fax Number:
662-342-0750
Provider Enumeration Date:
01/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BRADDY
Authorized Official First Name:
JARAD
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
662-393-0781

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3341-05 , 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)

  • Identifier: 082288765 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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