Provider Demographics
NPI:1629332762
Name:TROTTER, BRYANT COLLINS (DMD)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:COLLINS
Last Name:TROTTER
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 1:460 BYHALIA RD
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1319
Mailing Address - Country:US
Mailing Address - Phone:662-429-5239
Mailing Address - Fax:662-449-0758
Practice Address - Street 1:460 BYHALIA RD
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1319
Practice Address - Country:US
Practice Address - Phone:662-429-5239
Practice Address - Fax:662-449-0758
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3658-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice