Provider Demographics
NPI:1790875912
Name:HIRSBERG, BRYANT (DMD)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:HIRSBERG
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 1:785 OHIO AVE STE 3H
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6215
Mailing Address - Country:US
Mailing Address - Phone:662-627-9001
Mailing Address - Fax:662-627-3662
Practice Address - Street 1:785 OHIO AVE STE 3H
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6215
Practice Address - Country:US
Practice Address - Phone:662-627-9001
Practice Address - Fax:662-627-3662
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3042-98122300000X
MSOR-345-001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660374Medicaid