Provider Demographics
NPI:1588696777
Name:BRYAN, JIMMY (DMD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:BRYAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 DULCINEA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-4065
Mailing Address - Country:US
Mailing Address - Phone:702-499-5343
Mailing Address - Fax:
Practice Address - Street 1:1700 W CHARLESTON BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2335
Practice Address - Country:US
Practice Address - Phone:702-774-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist