Provider Demographics
NPI:1013438100
Name:SLACK, BRYCE E
Entity type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:E
Last Name:SLACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9169 W ALEX AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8344
Mailing Address - Country:US
Mailing Address - Phone:435-773-7175
Mailing Address - Fax:
Practice Address - Street 1:5400 W NORTHERN AVE STE 202
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1591
Practice Address - Country:US
Practice Address - Phone:623-500-5793
Practice Address - Fax:623-321-1030
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2025-02-20
Deactivation Date:2023-04-17
Deactivation Code:
Reactivation Date:2023-05-10
Provider Licenses
StateLicense IDTaxonomies
OK69791223G0001X
AZD0109401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice