Provider Demographics
NPI:1609888197
Name:HYDE, ERIC L (DDS PLLC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:HYDE
Suffix:
Gender:M
Credentials:DDS PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15236 DEDEAUX RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3161
Mailing Address - Country:US
Mailing Address - Phone:228-832-3111
Mailing Address - Fax:228-832-3117
Practice Address - Street 1:15236 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3161
Practice Address - Country:US
Practice Address - Phone:228-832-3111
Practice Address - Fax:228-832-3117
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3330-051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03781882Medicaid
MS04472876OtherMEDICAID GROUP NUMBER
MS510579833OtherTAX I.D. NUMBER