Main Street Dental

Primary specialty

DentistTaxonomy code 122300000X

License

3341-05 Issued in MS

Legal business name

MAIN STREET DENTAL

Practice address

8747 Northwest Dr
Southaven, MS 38671-2409

Phone

(662) 393-0781

Fax

(662) 342-0750

NPI assigned

Jan 10, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jarad BraddyNPI 1831119940

Title

Member

Phone

(662) 393-0781

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Drs. Joe Braddy & Simmons Former legal business name

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jarad Joseph Braddy, D.D.S.

  • General Practice Dentistry
  • Southaven, MS
  • NPI 1831119940
  NPD (past) Authorized official
• Daniel Rhett Simmons, D.M.D.

  • General Practice Dentistry
  • Southaven, MS
  • NPI 1861412975
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1357776000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1453939200000",
    "number": "1043557085",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8747 NORTHWEST DR",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386712409",
            "telephone_number": "662-393-0781",
            "fax_number": "662-342-0750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8747 NORTHWEST DR",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386712409",
            "telephone_number": "662-393-0781",
            "fax_number": "662-342-0750"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET DENTAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-01-10",
        "last_updated": "2016-01-28",
        "status": "A",
        "authorized_official_last_name": "BRADDY",
        "authorized_official_first_name": "JARAD",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "662-393-0781"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "MS",
            "license": "3341-05",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "082288765",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Drs. Joe Braddy & Simmons",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Magnolia Speech Therapy of Mississippi
• Magnolia Surgery Center, LLC
• Magriss PLLC
• Main Street Clinical Laboratory, Inc
• Main Street Clinical Laboratory, Inc
• Steven David Major, MD
• Jacqueline Anne Majors, M.D.
• Amit Malhotra, M.D.
• Sunil Malhotra, MD
• Whitney Malone

• All providers in Southaven, MS
• Dentist in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.