Provider Demographics
NPI:1629185178
Name:BRYSON, THEODORE PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:PAUL
Last Name:BRYSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1196
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-1196
Mailing Address - Country:US
Mailing Address - Phone:208-354-7878
Mailing Address - Fax:
Practice Address - Street 1:30 E. HARPER ST.
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5179
Practice Address - Country:US
Practice Address - Phone:208-354-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice