Provider Demographics
NPI:1609079482
Name:DEAVILA, BRYAN JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOSEPH
Last Name:DEAVILA
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 1:1422 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2177
Mailing Address - Country:US
Mailing Address - Phone:602-336-1111
Mailing Address - Fax:844-313-7604
Practice Address - Street 1:1422 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2177
Practice Address - Country:US
Practice Address - Phone:602-336-1111
Practice Address - Fax:844-313-7604
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice