Healthcare Provider Details

I. General information

NPI: 1114051133
Provider Name (Legal Business Name): LEE ANN BRADY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18301 N 79TH AVE F164
GLENDALE AZ
85308-8463
US

IV. Provider business mailing address

18301 N 79TH AVE F164
GLENDALE AZ
85308-8463
US

V. Phone/Fax

Practice location:
  • Phone: 480-204-9210
  • Fax:
Mailing address:
  • Phone: 480-204-9210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7734
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN11692
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: