Provider Demographics
NPI:1285630236
Name:BRYANT, GARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:BRYANT
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:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74477-0448
Mailing Address - Country:US
Mailing Address - Phone:918-485-4559
Mailing Address - Fax:918-485-4550
Practice Address - Street 1:104 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4320
Practice Address - Country:US
Practice Address - Phone:918-485-4559
Practice Address - Fax:918-485-4550
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice