Healthcare Provider Details

I. General information

NPI: 1194904094
Provider Name (Legal Business Name): BIERDEMAN OTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 RIVER RIDGE ROAD
JACKSON MS
39216-5018
US

IV. Provider business mailing address

2680 RIVER RIDGE ROAD
JACKSON MS
39216-5018
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-3036
  • Fax: 601-981-2959
Mailing address:
  • Phone: 601-981-3036
  • Fax: 601-981-2959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberOR15188
License Number StateMS

VIII. Authorized Official

Name: KARL LEE BIERDEMAN
Title or Position: PRESIDENT
Credential: DMD
Phone: 601-981-3036