Provider Demographics
NPI:1043457799
Name:BRYSON, RANDOLPH CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:CHARLES
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 1:123 WICKLOW DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-7329
Mailing Address - Country:US
Mailing Address - Phone:215-813-0819
Mailing Address - Fax:
Practice Address - Street 1:1350 GROVE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-2455
Practice Address - Country:US
Practice Address - Phone:803-387-0682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-17
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV49771223G0001X
SC92181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice