Provider Demographics
NPI:1669489290
Name:BREAZEALE, MUNDY SCOTT SR
Entity Type:Individual
Prefix:DR
First Name:MUNDY
Middle Name:SCOTT
Last Name:BREAZEALE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1952
Mailing Address - Country:US
Mailing Address - Phone:228-896-7022
Mailing Address - Fax:
Practice Address - Street 1:430 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1952
Practice Address - Country:US
Practice Address - Phone:228-896-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS271493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist