Healthcare Provider Details

I. General information

NPI: 1194701524
Provider Name (Legal Business Name): BRADLEY JOHN SMITH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 476 BOX1159
FPO AP
96322
JP

IV. Provider business mailing address

PSC 476 BOX1159
FPO AP
96322
JP

V. Phone/Fax

Practice location:
  • Phone: 314-252-3747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019024984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: