Provider Demographics
NPI:1770898751
Name:KATZ, BRYAN RUSSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RUSSELL
Last Name:KATZ
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 1:90 VANDENBERG DR
Mailing Address - Street 2:66 MDS (AFMC)
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2104
Mailing Address - Country:US
Mailing Address - Phone:781-225-6789
Mailing Address - Fax:781-225-2564
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:66 MDS (AFMC)
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:781-225-2564
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO24241001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice