Provider Demographics
NPI:1003113879
Name:OLIVE BRANCH ORTHODONTICS
Entity Type:Organization
Organization Name:OLIVE BRANCH ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:HIRSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-627-9001
Mailing Address - Street 1:785 OHIO AVE STE 3H
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6215
Mailing Address - Country:US
Mailing Address - Phone:662-627-9001
Mailing Address - Fax:662-627-3662
Practice Address - Street 1:785 OHIO AVE STE 3H
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6215
Practice Address - Country:US
Practice Address - Phone:662-627-9001
Practice Address - Fax:662-627-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3042-981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty