Provider Demographics
NPI:1043371008
Name:BRYSON, STEPHEN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
Last Name:BRYSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PROFESSIONAL LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2590
Mailing Address - Country:US
Mailing Address - Phone:606-573-6007
Mailing Address - Fax:606-573-4068
Practice Address - Street 1:110 PROFESSIONAL LN
Practice Address - Street 2:SUITE 201
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2590
Practice Address - Country:US
Practice Address - Phone:606-573-6007
Practice Address - Fax:606-573-4068
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003373Medicaid