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General NPI Number Information
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NPI Number | 1043557085
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL
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Dates
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Enumeration Date | 01/10/2013
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Last Update Date | 01/28/2016
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Provider Practice Location Address
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Address Line | 8747 NORTHWEST DR
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City | SOUTHAVEN
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State | MS
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Zip | 38671-2409
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Country | US
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Telephone | 662-393-0781
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Fax | 662-342-0750
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Provider Business Mailing Address
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Address Line | 8747 NORTHWEST DR
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City | SOUTHAVEN
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State | MS
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Zip | 38671-2409
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Country | US
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Telephone | 662-393-0781
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Fax | 662-342-0750
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Authorized Official
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Title or Position | MEMBER
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Name | JARAD BRADDY
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Credential |
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Telephone | 662-393-0781
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3341-05
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License Number State | MS
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