Healthcare Provider Details

I. General information

NPI: 1285610675
Provider Name (Legal Business Name): BRYAN DENT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

1400 HOSPITAL DR
HURRICANE WV
25526-9202
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-4155
  • Fax:
Mailing address:
  • Phone: 800-875-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00627
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: