Provider Demographics
NPI:1003221748
Name:BRAASCH, BRYAN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DAVID
Last Name:BRAASCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5570
Mailing Address - Country:US
Mailing Address - Phone:260-417-4981
Mailing Address - Fax:
Practice Address - Street 1:6821 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-5570
Practice Address - Country:US
Practice Address - Phone:260-417-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012182A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist