Provider Demographics
NPI:1972146470
Name:BRYAN A WEYNETH DDS PC
Entity type:Organization
Organization Name:BRYAN A WEYNETH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT CONTRACT LABOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING AGENT
Authorized Official - Phone:928-779-4404
Mailing Address - Street 1:1100 SHERMAN AVE STE 1031100
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8608
Mailing Address - Country:US
Mailing Address - Phone:630-369-5225
Mailing Address - Fax:630-369-7416
Practice Address - Street 1:1100 SHERMAN AVE STE 1031100
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8608
Practice Address - Country:US
Practice Address - Phone:630-369-5225
Practice Address - Fax:630-369-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty