Provider Demographics
NPI:1285003210
Name:STEWART, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:STEWART
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 1:1625 RIO BRAVO BLVD SW
Mailing Address - Street 2:SUITE 33
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6057
Mailing Address - Country:US
Mailing Address - Phone:505-431-6779
Mailing Address - Fax:505-212-0789
Practice Address - Street 1:1625 RIO BRAVO BLVD SW
Practice Address - Street 2:SUITE 33
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6057
Practice Address - Country:US
Practice Address - Phone:505-431-6779
Practice Address - Fax:505-212-0789
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist