Provider Demographics
NPI:1871720854
Name:WELCH, BRYAN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:THOMAS
Last Name:WELCH
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 424
Mailing Address - Street 2:
Mailing Address - City:ATTICA
Mailing Address - State:IN
Mailing Address - Zip Code:47918-0424
Mailing Address - Country:US
Mailing Address - Phone:765-762-2621
Mailing Address - Fax:765-762-3610
Practice Address - Street 1:904 S COUNCIL ST
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:IN
Practice Address - Zip Code:47918-1606
Practice Address - Country:US
Practice Address - Phone:765-762-2621
Practice Address - Fax:765-762-3610
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011296A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist