Provider Demographics
NPI:1578841474
Name:BEHM, BRYAN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JAMES
Last Name:BEHM
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 1:2410 SAMPSON ST
Mailing Address - Street 2:BLDG 237
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-2942
Mailing Address - Country:US
Mailing Address - Phone:847-688-2469
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMPSON ST
Practice Address - Street 2:BLDG 237
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2942
Practice Address - Country:US
Practice Address - Phone:847-688-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6710-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist