Provider Demographics
NPI:1275930091
Name:BRYAN, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2059
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-2059
Mailing Address - Country:US
Mailing Address - Phone:252-473-5774
Mailing Address - Fax:252-473-3871
Practice Address - Street 1:2038 NC 345 HIGHWAY SOUT
Practice Address - Street 2:
Practice Address - City:WANCHESE
Practice Address - State:NC
Practice Address - Zip Code:27981
Practice Address - Country:US
Practice Address - Phone:252-473-5774
Practice Address - Fax:252-473-3871
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist