Healthcare Provider Details

I. General information

NPI: 1861691297
Provider Name (Legal Business Name): MR. BRYAN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 STONE GLEN LN
CARROLLTON TX
75007-2004
US

IV. Provider business mailing address

2303 STONE GLEN LN
CARROLLTON TX
75007-2004
US

V. Phone/Fax

Practice location:
  • Phone: 945-217-8468
  • Fax:
Mailing address:
  • Phone: 945-217-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number50542-0726
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: