MEDICARE: BRYAN KEITH ANGEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	3321	AR

General Provider Information

NPI Number	:	1013127505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRYAN KEITH ANGEL

Provider Business Mailing Address
First Line	:	300 S RODNEY PARHAM RD STE 3
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4774
Country	:	US
Telephone Number	:	501-224-4799
Fax Number	:	501-224-9278

Provider Business Practice Location Address
First Line	:	300 S RODNEY PARHAM RD STE 3
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4774
Country	:	US
Telephone Number	:	501-224-4799
Fax Number	:	501-224-9278

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRYAN KEITH ANGEL
Credential	:	DDS
Telephone Number	:	501-224-4799

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/22/2020

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