MEDICARE: JIMMY BRYAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0646	NV

General Provider Information

NPI Number	:	1588696777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMY BRYAN DMD

Provider Business Mailing Address
First Line	:	2695 DULCINEA DR
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-4065
Country	:	US
Telephone Number	:	702-499-5343
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 W CHARLESTON BLVD BLDG A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2335
Country	:	US
Telephone Number	:	702-774-2400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	09/06/2019

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