Provider Demographics
NPI:1063432706
Name:BRYAN, CHARLES LLOYD (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LLOYD
Last Name:BRYAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:L
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4417 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2401
Mailing Address - Country:US
Mailing Address - Phone:405-789-5566
Mailing Address - Fax:
Practice Address - Street 1:4417 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2401
Practice Address - Country:US
Practice Address - Phone:405-789-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3144122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist