Healthcare Provider Details

I. General information

NPI: 1942488036
Provider Name (Legal Business Name): ROLAND R BRYAN DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 SOUTH MAIN ST SUITE 100
MUNCHESTER NH
03102
US

IV. Provider business mailing address

769 SOUTH MAIN ST SUITE 100
MUNCHESTER NH
03102
US

V. Phone/Fax

Practice location:
  • Phone: 603-623-3800
  • Fax: 603-623-7867
Mailing address:
  • Phone: 603-623-3800
  • Fax: 603-623-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2516
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2516
License Number StateNH

VIII. Authorized Official

Name: ROLAND R BRYAN
Title or Position: PERIODONTIST
Credential: DMD
Phone: 603-623-3800