Provider Demographics
NPI:1639424963
Name:O'BRYAN DENTAL CLINIC
Entity Type:Organization
Organization Name:O'BRYAN DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-825-0559
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS318201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08533712Medicaid