Provider Demographics
NPI:1194092148
Name:LARRY W. BRYANT DDS, PC
Entity type:Organization
Organization Name:LARRY W. BRYANT DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:WINFRED
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-249-0553
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 236-240
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-249-0553
Mailing Address - Fax:301-249-0555
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:SUITE 236-240
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-249-0553
Practice Address - Fax:301-249-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD077381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU34665Medicare UPIN