Provider Demographics
NPI:1528710761
Name:CHILDRENS DENTAL CENTER HERNANDO LLC
Entity type:Organization
Organization Name:CHILDRENS DENTAL CENTER HERNANDO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:RHOADS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:901-258-9275
Mailing Address - Street 1:1150 MONTEITH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8157
Mailing Address - Country:US
Mailing Address - Phone:662-298-2105
Mailing Address - Fax:205-419-9104
Practice Address - Street 1:1150 MONTEITH AVE STE 102
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-8157
Practice Address - Country:US
Practice Address - Phone:662-298-2105
Practice Address - Fax:205-419-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty