Provider Demographics
NPI:1073723003
Name:BRYANT, WALTER ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ROBERT
Last Name:BRYANT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 SPRING CENTRE SOUTH BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-1976
Mailing Address - Country:US
Mailing Address - Phone:407-628-9523
Mailing Address - Fax:
Practice Address - Street 1:1173 SPRING CENTRE SOUTH BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-1976
Practice Address - Country:US
Practice Address - Phone:407-628-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN81211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070427000Medicaid