Provider Demographics
NPI:1477661684
Name:BRYAN, MERRIL (DDS)
Entity Type:Individual
Prefix:
First Name:MERRIL
Middle Name:
Last Name:BRYAN
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 1956
Mailing Address - Street 2:112 SIXTH AVE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040
Mailing Address - Country:US
Mailing Address - Phone:928-645-3206
Mailing Address - Fax:928-645-9139
Practice Address - Street 1:112 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-3206
Practice Address - Fax:928-645-9139
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD15271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ084004OtherAHCCCS