Provider Demographics
NPI:1043284128
Name:BRYAN, MICHAEL DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:BRYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6003
Mailing Address - Country:US
Mailing Address - Phone:817-416-9731
Mailing Address - Fax:817-416-9751
Practice Address - Street 1:660 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6003
Practice Address - Country:US
Practice Address - Phone:817-416-9731
Practice Address - Fax:817-416-9751
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1503207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0052ETOtherBCBS
TX113601203Medicaid
TX5675166OtherAETNA
TX0052ETOtherBCBS
G33200Medicare UPIN