Provider Demographics
NPI:1871630822
Name:KACY, BRYAN D (DDS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:KACY
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 1:77 W SQUARE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2929
Mailing Address - Country:US
Mailing Address - Phone:248-879-2980
Mailing Address - Fax:248-879-2983
Practice Address - Street 1:77 W SQUARE LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2929
Practice Address - Country:US
Practice Address - Phone:248-879-2980
Practice Address - Fax:248-879-2983
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010179981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice