Provider Demographics
NPI:1215141346
Name:FRYAR, BRIAN C (DDS,MSD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:FRYAR
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 A ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5925
Mailing Address - Country:US
Mailing Address - Phone:219-362-5500
Mailing Address - Fax:
Practice Address - Street 1:1700 A ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5925
Practice Address - Country:US
Practice Address - Phone:219-362-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1200-8697A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics