Provider Demographics
NPI:1417107384
Name:ILUSTRE, JOSEPH BRYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BRYAN
Last Name:ILUSTRE
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 1:3695 KIRBY DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-5534
Mailing Address - Country:US
Mailing Address - Phone:281-941-5488
Mailing Address - Fax:
Practice Address - Street 1:3695 KIRBY DR STE 129
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-5544
Practice Address - Country:US
Practice Address - Phone:281-941-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice