Provider Demographics
NPI:1003826314
Name:ANGEL, BRYAN KEITH (DDS, PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:ANGEL
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S RODNEY PARHAM RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4747
Mailing Address - Country:US
Mailing Address - Phone:501-224-4799
Mailing Address - Fax:501-224-9278
Practice Address - Street 1:300 S RODNEY PARHAM RD
Practice Address - Street 2:SUITE 3
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4747
Practice Address - Country:US
Practice Address - Phone:501-224-4799
Practice Address - Fax:501-224-9278
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145950608Medicaid