Provider Demographics
NPI:1154431765
Name:STAHL, BRYAN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DAVID
Last Name:STAHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021
Mailing Address - Country:US
Mailing Address - Phone:847-516-1933
Mailing Address - Fax:
Practice Address - Street 1:1109 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021
Practice Address - Country:US
Practice Address - Phone:847-516-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice