Provider Demographics
NPI:1831580620
Name:LARA, BRYAN A (DDS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:A
Last Name:LARA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BRYAN
Other - Middle Name:A
Other - Last Name:LARA MUNOZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDX
Mailing Address - Street 1:1100 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2715
Mailing Address - Country:US
Mailing Address - Phone:864-386-0273
Mailing Address - Fax:
Practice Address - Street 1:110 AUSTON WOODS CIR
Practice Address - Street 2:APT U
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-4301
Practice Address - Country:US
Practice Address - Phone:864-243-7534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-15
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAP-1831223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program