Provider Demographics
NPI:1417015082
Name:BYRNSIDE, BRYAN D (MD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:D
Last Name:BYRNSIDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W CALDWELL ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-2910
Mailing Address - Country:US
Mailing Address - Phone:615-758-7511
Mailing Address - Fax:615-827-0202
Practice Address - Street 1:40 W. CALDWELL STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122
Practice Address - Country:US
Practice Address - Phone:615-758-7511
Practice Address - Fax:615-827-0202
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS83711223P0221X
TN83711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511981Medicaid