MEDICARE: BRYANT HIRSBERG DMD

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	122300000X	Dentist	3042-98	MS
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	OR-345-00	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790875912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYANT HIRSBERG DMD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	04/27/2018

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Directions to “ BRYANT HIRSBERG DMD” Practice Location

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