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General NPI Number Information
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NPI Number | 1942862735
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Entity Type | Individual
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Provider Name | BRYANT ANTHONY IRAWAN
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Gender | Male
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Dates
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Enumeration Date | 07/02/2019
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 2643 APPIAN WAY STE B
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City | PINOLE
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State | CA
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Zip | 94564-2253
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Country | US
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Telephone | 510-758-0900
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Fax |
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Provider Business Mailing Address
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Address Line | 1685 7TH AVE
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City | SAN FRANCISCO
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State | CA
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Zip | 94122-3716
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Country | US
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Telephone | 626-340-3404
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 103922
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License Number State | CA
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