Provider Demographics
NPI:1922267491
Name:DR. BRYAN DRYDEN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:DR. BRYAN DRYDEN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. BRYAN DRYDEN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:RADAR
Authorized Official - Last Name:DRYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-664-9506
Mailing Address - Street 1:509 W HANLEY AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8994
Mailing Address - Country:US
Mailing Address - Phone:208-664-9506
Mailing Address - Fax:208-665-1598
Practice Address - Street 1:509 W HANLEY AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8994
Practice Address - Country:US
Practice Address - Phone:208-664-9506
Practice Address - Fax:208-665-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3332261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental