Healthcare Provider Details

I. General information

NPI: 1184465478
Provider Name (Legal Business Name): BRYAN TRUONG DDS, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 NAIL RD E STE 103
SOUTHAVEN MS
38672-6715
US

IV. Provider business mailing address

843 VINSON RD
HERNANDO MS
38632-7241
US

V. Phone/Fax

Practice location:
  • Phone: 662-893-7337
  • Fax:
Mailing address:
  • Phone: 770-861-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number112351
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13060
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: