=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275681967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE BELT PERIODONTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 MEDICAL BLVD
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-7231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-264-2424
-----------------------------------------------------
Fax | 601-264-2410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 MEDICAL BLVD
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-7231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-264-2424
-----------------------------------------------------
Fax | 601-264-2410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. BRIAN ALEXANDER PITFIELD
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 601-264-2424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2568-90
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------