Provider Demographics
NPI:1659788511
Name:BRYAN, JELANA RENEE (DMD)
Entity Type:Individual
Prefix:
First Name:JELANA
Middle Name:RENEE
Last Name: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:PO BOX 71926
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-1926
Mailing Address - Country:US
Mailing Address - Phone:470-241-0143
Mailing Address - Fax:
Practice Address - Street 1:38 JEFFERSON PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5812
Practice Address - Country:US
Practice Address - Phone:470-241-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist