Provider Demographics
NPI:1275648701
Name:COUSIN, BRYAN PHILLIP (DMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:PHILLIP
Last Name:COUSIN
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 1:205 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2745
Mailing Address - Country:US
Mailing Address - Phone:781-598-1180
Mailing Address - Fax:
Practice Address - Street 1:205 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2745
Practice Address - Country:US
Practice Address - Phone:781-598-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice