Healthcare Provider Details

I. General information

NPI: 1235339284
Provider Name (Legal Business Name): WREN PEDIATRIC DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 W GOVERNMENT ST SUITE B
BRANDON MS
39042-3272
US

IV. Provider business mailing address

1390 W GOVERNMENT ST SUITE B
BRANDON MS
39042-3272
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-0093
  • Fax: 601-825-0240
Mailing address:
  • Phone: 601-824-0093
  • Fax: 601-825-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberPEDO-402-07
License Number StateMS

VIII. Authorized Official

Name: DR. JOSH WREN
Title or Position: OWNER
Credential: DMD
Phone: 601-824-0093