Provider Demographics
NPI:1043557085
Name:MAIN STREET DENTAL
Entity Type:Organization
Organization Name:MAIN STREET DENTAL
Other - Org Name:DRS. JOE BRADDY & SIMMONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JARAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-393-0781
Mailing Address - Street 1:8747 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2409
Mailing Address - Country:US
Mailing Address - Phone:662-393-0781
Mailing Address - Fax:662-342-0750
Practice Address - Street 1:8747 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2409
Practice Address - Country:US
Practice Address - Phone:662-393-0781
Practice Address - Fax:662-342-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3341-05122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS082288765Medicaid