Provider Demographics
NPI:1467583161
Name:BAUER, BRYAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BAUER
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 1:1547 ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7201
Mailing Address - Country:US
Mailing Address - Phone:312-371-6831
Mailing Address - Fax:
Practice Address - Street 1:531 E ROOSEVELT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5583
Practice Address - Country:US
Practice Address - Phone:630-665-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190263801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice