Provider Demographics
NPI:1811419674
Name:BRYAN, CHRISTA JEAULEA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTA
Middle Name:JEAULEA
Last Name:BRYAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 YATES AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1611
Mailing Address - Country:US
Mailing Address - Phone:304-265-2438
Mailing Address - Fax:304-265-1545
Practice Address - Street 1:122 YATES AVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1611
Practice Address - Country:US
Practice Address - Phone:304-265-2438
Practice Address - Fax:304-265-1545
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
000090295OtherUNITED CONCORDIA
WV0136411000Medicaid