MEDICARE: DR. BRADLEY JOHN BATH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12008674	IN

General Provider Information

NPI Number	:	1396855763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY JOHN BATH D.D.S.

Provider Business Mailing Address
First Line	:	5200 WASHINGTON AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-4863
Country	:	US
Telephone Number	:	812-476-6064
Fax Number	:	812-476-6091

Provider Business Practice Location Address
First Line	:	5200 WASHINGTON AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-4863
Country	:	US
Telephone Number	:	812-476-6064
Fax Number	:	812-476-6091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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