Healthcare Provider Details

I. General information

NPI: 1861466385
Provider Name (Legal Business Name): JOE BRYANT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20329 N 59TH AVE SUITE A-11
GLENDALE AZ
85308-6853
US

IV. Provider business mailing address

20329 N 59TH AVE SUITE A-11
GLENDALE AZ
85308-6853
US

V. Phone/Fax

Practice location:
  • Phone: 623-362-2000
  • Fax: 623-376-2393
Mailing address:
  • Phone: 623-362-2000
  • Fax: 623-376-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: