=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003113879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYANT HIRSBERG DMD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2011
-----------------------------------------------------
Last Update Date | 03/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 OHIO AVE STE 3H
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-9001
-----------------------------------------------------
Fax | 662-627-3662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 785 OHIO AVE STE 3H
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-9001
-----------------------------------------------------
Fax | 662-627-3662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | NICOLE CARIDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-784-2721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------