Provider Demographics
NPI:1700347747
Name:HALSTEAD, BRYAN (DMD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HALSTEAD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ONTARIO CT
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-8706
Mailing Address - Country:US
Mailing Address - Phone:912-286-0352
Mailing Address - Fax:
Practice Address - Street 1:15 RUTH DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2317
Practice Address - Country:US
Practice Address - Phone:770-253-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0159001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice