Provider Demographics
NPI:1053666701
Name:BRYANT-THOMAS, ALICIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:
Last Name:BRYANT-THOMAS
Suffix:
Gender:F
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:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1490
Mailing Address - Country:US
Mailing Address - Phone:912-764-6149
Mailing Address - Fax:912-764-3863
Practice Address - Street 1:219 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2001
Practice Address - Country:US
Practice Address - Phone:912-764-6149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0144181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice