Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 021.003056 | IL |
NPI | 1124368584 |
---|---|
Provider Name | Scott Bryant |
First Address | Scott Afb, IL 62225 |
Second Address | Scott Afb, IL 62225 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2013 |
Last Update Date | 18/09/2020 |