Provider Demographics
NPI:1083832422
Name:HATTIESBURG ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:HATTIESBURG ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:FALER
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:601-450-2141
Mailing Address - Street 1:704 S 28TH AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2524
Mailing Address - Country:US
Mailing Address - Phone:601-450-2141
Mailing Address - Fax:
Practice Address - Street 1:704 S 28TH AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2524
Practice Address - Country:US
Practice Address - Phone:601-450-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3110-991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty