MEDICARE: BRYANT HIRSBERG DMD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1003113879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRYANT HIRSBERG DMD, INC.

Provider Business Mailing Address
First Line	:	785 OHIO AVE STE 3H
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-6215
Country	:	US
Telephone Number	:	662-627-9001
Fax Number	:	662-627-3662

Provider Business Practice Location Address
First Line	:	785 OHIO AVE STE 3H
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-6215
Country	:	US
Telephone Number	:	662-627-9001
Fax Number	:	662-627-3662

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	NICOLE CARIDE
Credential	:
Telephone Number	:	727-784-2721

Provider Enumeration Date	:	02/14/2011
Last Update Date	:	03/13/2025

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