Provider Demographics
NPI:1316060411
Name:BISHOP, BRYAN WILSON (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WILSON
Last Name:BISHOP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BRYAN
Other - Middle Name:W
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1917 NEW YORK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010
Mailing Address - Country:US
Mailing Address - Phone:817-275-2601
Mailing Address - Fax:817-275-2625
Practice Address - Street 1:1917 NEW YORK AVENUE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010
Practice Address - Country:US
Practice Address - Phone:817-275-2601
Practice Address - Fax:817-275-2625
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1393448OtherUNITED CONCORDIA
85D268OtherBLUE CROSS BLUE SHIELD