Provider Demographics
NPI:1710149521
Name:BISHOP, BRYAN W (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:BISHOP
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:PO BOX 3500
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-3500
Mailing Address - Country:US
Mailing Address - Phone:479-996-1717
Mailing Address - Fax:479-996-1335
Practice Address - Street 1:1742 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936-3420
Practice Address - Country:US
Practice Address - Phone:479-996-1717
Practice Address - Fax:479-996-1335
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176538608Medicaid