Provider Demographics
NPI:1245965797
Name:BRYANT & LARSON. A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:BRYANT & LARSON. A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:R
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-686-6410
Mailing Address - Street 1:6886 INDIANA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4218
Mailing Address - Country:US
Mailing Address - Phone:951-686-6410
Mailing Address - Fax:
Practice Address - Street 1:6886 INDIANA AVE STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4218
Practice Address - Country:US
Practice Address - Phone:951-686-6410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARSON ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty