Provider Demographics
NPI:1821316092
Name:BAIN, BRIAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:BAIN
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 1:429 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-1405
Mailing Address - Country:US
Mailing Address - Phone:770-258-5516
Mailing Address - Fax:770-258-5517
Practice Address - Street 1:831 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4415
Practice Address - Country:US
Practice Address - Phone:770-832-9668
Practice Address - Fax:678-601-1574
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist