Healthcare Provider Details

I. General information

NPI: 1174275762
Provider Name (Legal Business Name): DELTA ORTHODONTIC SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 GROVE STREET
VICKSBURG MS
39183-2857
US

IV. Provider business mailing address

2356 GROVE STREET
VICKSBURG MS
39183-2857
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-8230
  • Fax: 601-636-3388
Mailing address:
  • Phone: 601-638-8230
  • Fax: 601-636-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD V BROWN III
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 601-636-3388