Healthcare Provider Details

I. General information

NPI: 1265696769
Provider Name (Legal Business Name): BRANTLEY PAUL NICHOLS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N OAK AVE
RULEVILLE MS
38771-3227
US

IV. Provider business mailing address

PO BOX 10270
GREENWOOD MS
38930-0270
US

V. Phone/Fax

Practice location:
  • Phone: 601-624-8209
  • Fax:
Mailing address:
  • Phone: 601-624-8209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8276
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3560-10
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: