Provider Demographics
NPI:1174673222
Name:MEDARIS, BRYAN REED (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:REED
Last Name:MEDARIS
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 1:12231 W CARIBEE INLET DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5653
Mailing Address - Country:US
Mailing Address - Phone:208-286-0470
Mailing Address - Fax:
Practice Address - Street 1:4411 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3113
Practice Address - Country:US
Practice Address - Phone:208-466-3597
Practice Address - Fax:208-466-8147
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice