Healthcare Provider Details

I. General information

NPI: 1164499109
Provider Name (Legal Business Name): BARRY SAUL RUBEL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1087 STUMP RIDGE RD
BRANDON MS
39047-9316
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6030
  • Fax: 601-984-6039
Mailing address:
  • Phone: 601-829-1364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4883
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberPRV-TP-107-04
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: