Healthcare Provider Details

I. General information

NPI: 1992372023
Provider Name (Legal Business Name): BRYAN MEADOWS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S PIKE ST
SHINNSTON WV
26431-1125
US

IV. Provider business mailing address

1709 BRUNSWICK CT
MORGANTOWN WV
26508-4811
US

V. Phone/Fax

Practice location:
  • Phone: 304-592-0600
  • Fax:
Mailing address:
  • Phone: 304-237-1893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4523
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: