=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972625598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN QUOC BUI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 07/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4054 BUFORD HWY NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30345-1678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-477-5665
-----------------------------------------------------
Fax | 404-477-5666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 CREEK WIND CT
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-7149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-862-5353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 48089
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN015536
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------