Healthcare Provider Details

I. General information

NPI: 1972146470
Provider Name (Legal Business Name): BRYAN A WEYNETH DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SHERMAN AVE STE 1031100
NAPERVILLE IL
60563-8608
US

IV. Provider business mailing address

1100 SHERMAN AVE STE 1031100
NAPERVILLE IL
60563-8608
US

V. Phone/Fax

Practice location:
  • Phone: 630-369-5225
  • Fax: 630-369-7416
Mailing address:
  • Phone: 630-369-5225
  • Fax: 630-369-7416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DOROTHY HERNANDEZ
Title or Position: CREDENTIALING AGENT CONTRACT LABOR
Credential: CREDENTIALING AGENT
Phone: 928-779-4404