Provider Demographics
NPI:1649441437
Name:BRYAN, EDWARD PHILLIP
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PHILLIP
Last Name:BRYAN
Suffix:
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 1:3019 WEST SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043
Mailing Address - Country:US
Mailing Address - Phone:323-292-6267
Mailing Address - Fax:323-292-9216
Practice Address - Street 1:3019 WEST SLAUSON AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043
Practice Address - Country:US
Practice Address - Phone:323-292-6267
Practice Address - Fax:323-292-9216
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist