Provider Demographics
NPI:1619005972
Name:ENDODONTIC ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:ENDODONTIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:PRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-856-6364
Mailing Address - Street 1:301 NORTHLAKE AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1718
Mailing Address - Country:US
Mailing Address - Phone:601-856-6364
Mailing Address - Fax:601-856-7545
Practice Address - Street 1:301 NORTHLAKE AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1718
Practice Address - Country:US
Practice Address - Phone:601-856-6364
Practice Address - Fax:601-856-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSENDO 239931223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty