| Main Street Dental | |
|
8747 Northwest Dr Southaven MS 38671-2409 | |
| (662) 393-0781 | |
| (662) 342-0750 |
| Full Name | Main Street Dental |
|---|---|
| Speciality | Dentist |
| Location | 8747 Northwest Dr, Southaven, Mississippi |
| Authorized Official Name and Position | Jarad Braddy (MEMBER) |
| Authorized Official Contact | 6623930781 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Main Street Dental 8747 Northwest Dr Southaven MS 38671-2409 Ph: (662) 393-0781 | Main Street Dental 8747 Northwest Dr Southaven MS 38671-2409 Ph: (662) 393-0781 |
| NPI Number | 1043557085 |
|---|---|
| Provider Enumeration Date | 01/10/2013 |
| Last Update Date | 01/28/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043557085 | NPI | - | NPPES |
| 082288765 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 3341-05 (Mississippi) | Primary |
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