Provider Demographics
NPI:1548430697
Name:O'BRYAN, TANYA M (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:M
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6181 HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8296
Mailing Address - Country:US
Mailing Address - Phone:601-825-0559
Mailing Address - Fax:601-825-0374
Practice Address - Street 1:6181 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-8296
Practice Address - Country:US
Practice Address - Phone:601-825-0559
Practice Address - Fax:601-825-0374
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3182011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660415Medicaid