Healthcare Provider Details

I. General information

NPI: 1982924981
Provider Name (Legal Business Name): BRYAN DOUGLAS FREEMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 WYATT DR
MAYFIELD KY
42066-6810
US

IV. Provider business mailing address

312 WYATT DR
MAYFIELD KY
42066-6810
US

V. Phone/Fax

Practice location:
  • Phone: 270-247-1966
  • Fax: 270-247-5471
Mailing address:
  • Phone: 270-247-1966
  • Fax: 270-247-5471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8882
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: