Healthcare Provider Details

I. General information

NPI: 1366636748
Provider Name (Legal Business Name): BRAD BRYAN, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S UNIVERSITY AVE
LITTLE ROCK AR
72204
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6407
US

V. Phone/Fax

Practice location:
  • Phone: 770-916-9000
  • Fax:
Mailing address:
  • Phone: 770-916-5028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DALE MAYFIELD
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-916-5036