Provider Demographics
NPI:1235339284
Name:WREN PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:WREN PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-824-0093
Mailing Address - Street 1:1390 W GOVERNMENT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3272
Mailing Address - Country:US
Mailing Address - Phone:601-824-0093
Mailing Address - Fax:601-825-0240
Practice Address - Street 1:1390 W GOVERNMENT ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3272
Practice Address - Country:US
Practice Address - Phone:601-824-0093
Practice Address - Fax:601-825-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO-402-071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07707591Medicaid