Healthcare Provider Details

I. General information

NPI: 1508770058
Provider Name (Legal Business Name): GLUCKSTADT DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 GLUCKSTADT RD BLDG 100
GLUCKSTADT MS
39110-9425
US

IV. Provider business mailing address

1085 GLUCKSTADT RD BLDG 100
GLUCKSTADT MS
39110-9425
US

V. Phone/Fax

Practice location:
  • Phone: 601-898-2228
  • Fax:
Mailing address:
  • Phone: 601-898-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRADEN MCINTEER
Title or Position: OWNER/PARTNER
Credential: DMD
Phone: 601-898-2228