Provider Demographics
NPI:1144528381
Name:BRADDY-BROWN, KRYSTEL (DDS)
Entity type:Individual
Prefix:DR
First Name:KRYSTEL
Middle Name:
Last Name:BRADDY-BROWN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 MCCULLOUGH MCLIN RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-7928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 RIDGE WAY UNIT 3
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3303
Practice Address - Country:US
Practice Address - Phone:601-566-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-12
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS3716-13122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2890263Medicaid