Provider Demographics
NPI:1083688162
Name:O'BRYAN, DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8422 M 119
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9595
Mailing Address - Country:US
Mailing Address - Phone:231-348-1255
Mailing Address - Fax:231-348-3898
Practice Address - Street 1:8422 M 119
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9595
Practice Address - Country:US
Practice Address - Phone:231-348-1255
Practice Address - Fax:231-348-3898
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900B46505OtherBCBS
MI94-5071239Medicaid
MIDO002558OtherMI LICENCE
MI0B46505Medicare PIN
MIDO002558OtherMI LICENCE
MI6117710001Medicare NSC