Provider Demographics
NPI:1548618622
Name:HOLIFIELD, BRAD (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
Last Name:HOLIFIELD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-1422
Mailing Address - Country:US
Mailing Address - Phone:601-649-3900
Mailing Address - Fax:601-264-2723
Practice Address - Street 1:3221 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1422
Practice Address - Country:US
Practice Address - Phone:601-649-3900
Practice Address - Fax:601-264-2723
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1890-80122300000X
MSPER-201-87122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist