Provider Demographics
NPI:1083915474
Name:BAILEY, BRIAN EDWIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWIN
Last Name:BAILEY
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 1:13011 S 104TH AVE
Mailing Address - Street 2:SUITE # 209
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1506
Mailing Address - Country:US
Mailing Address - Phone:708-974-0278
Mailing Address - Fax:
Practice Address - Street 1:13011 S 104TH AVE
Practice Address - Street 2:SUITE # 209
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1506
Practice Address - Country:US
Practice Address - Phone:708-974-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0273831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice