Provider Demographics
NPI:1881806354
Name:PRIDE, JEFFERY BRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:BRIAN
Last Name:PRIDE
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 1:112 HADDINGTON CV
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6878
Mailing Address - Country:US
Mailing Address - Phone:601-853-0678
Mailing Address - Fax:
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:601-956-9380
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2197-851223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics