Basic Information
Provider Information | |||||||||
NPI: | 1972625598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUI | ||||||||
FirstName: | BRYAN | ||||||||
MiddleName: | QUOC | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 715 CREEK WIND CT | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | GA | ||||||||
PostalCode: | 300977149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5108625353 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4054 BUFORD HWY NE | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303451678 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4044775665 | ||||||||
FaxNumber: | 4044775666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 07/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 48089 | CA | N |   | Dental Providers | Dentist |   | 1223G0001X | DN015536 | GA | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.