Provider Demographics
NPI:1285173096
Name:BRYAN ROAD DENTISTRY
Entity type:Organization
Organization Name:BRYAN ROAD DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-585-7677
Mailing Address - Street 1:210 S BRYAN RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6204
Mailing Address - Country:US
Mailing Address - Phone:956-585-7677
Mailing Address - Fax:956-585-7627
Practice Address - Street 1:210 S BRYAN RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6204
Practice Address - Country:US
Practice Address - Phone:956-585-7677
Practice Address - Fax:956-585-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty