Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 12012182A | IN |
NPI | 1003221748 |
---|---|
Provider Name | Dr. Bryan David Braasch |
First Address | Fort Wayne, IN 46815-5570 |
Second Address | Fort Wayne, IN 46815-5570 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2014 |
Last Update Date | 20/06/2014 |