Healthcare Provider Details

I. General information

NPI: 1629332762
Provider Name (Legal Business Name): BRYANT COLLINS TROTTER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BYHALIA RD
HERNANDO MS
38632-1319
US

IV. Provider business mailing address

460 BYHALIA RD
HERNANDO MS
38632-1319
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5239
  • Fax: 662-449-0758
Mailing address:
  • Phone: 662-429-5239
  • Fax: 662-449-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3658-12
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: