Provider Demographics
NPI:1396022497
Name:G. DODD BRISTER, JR., DDS, PA
Entity Type:Organization
Organization Name:G. DODD BRISTER, JR., DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:DODD
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-824-5878
Mailing Address - Street 1:3007 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-8712
Mailing Address - Country:US
Mailing Address - Phone:601-824-5878
Mailing Address - Fax:
Practice Address - Street 1:3007 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-8712
Practice Address - Country:US
Practice Address - Phone:601-824-5878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOR222921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660332Medicaid