MEDICARE: BRADLEY DENTAL

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2451596	MI
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		MI
3	332BC3200X	Customized Equipment (DME)	15917	MI
4	1223G0001X	General Practice Dentistry	15917	MI

General Provider Information

NPI Number	:	1770848129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY DENTAL

Provider Business Mailing Address
First Line	:	21635 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48091-2788
Country	:	US
Telephone Number	:	586-757-7540
Fax Number	:

Provider Business Practice Location Address
First Line	:	21635 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48091-2788
Country	:	US
Telephone Number	:	586-757-7540
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DANA HORSCH
Credential	:
Telephone Number	:	586-757-7540

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	09/09/2014

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Directions to “BRADLEY DENTAL ” Practice Location

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