Provider Demographics
NPI:1891219499
Name:BRYAN PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BRYAN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-903-9276
Mailing Address - Street 1:1709 GLADE ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-4341
Mailing Address - Country:US
Mailing Address - Phone:317-903-9276
Mailing Address - Fax:
Practice Address - Street 1:2510 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2329
Practice Address - Country:US
Practice Address - Phone:317-903-9276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty