Provider Demographics
NPI:1750050159
Name:PASCAGOULA FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:PASCAGOULA FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BRASWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-584-9481
Mailing Address - Street 1:139 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3613-A HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581
Practice Address - Country:US
Practice Address - Phone:228-769-1244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty