Provider Demographics
NPI:1952318628
Name:BRYAN, RANSOM L JR
Entity Type:Individual
Prefix:
First Name:RANSOM
Middle Name:L
Last Name:BRYAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 STONEHENGE CIR
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-4330
Mailing Address - Country:US
Mailing Address - Phone:803-637-5580
Mailing Address - Fax:
Practice Address - Street 1:901 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:EDGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-4330
Practice Address - Country:US
Practice Address - Phone:803-637-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ-20941Medicaid