Provider Demographics
NPI:1194052373
Name:SOUTH MISSISSIPPI ENDODONTICS PA
Entity type:Organization
Organization Name:SOUTH MISSISSIPPI ENDODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-756-2307
Mailing Address - Street 1:1721 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2109
Mailing Address - Country:US
Mailing Address - Phone:228-267-3511
Mailing Address - Fax:601-510-4448
Practice Address - Street 1:1721 MEDICAL PARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2109
Practice Address - Country:US
Practice Address - Phone:228-267-3511
Practice Address - Fax:601-510-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3122-001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty