Healthcare Provider Details

I. General information

NPI: 1962533919
Provider Name (Legal Business Name): BRADLEY A. ELI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 MANCHESTER AVE SUITE 101
ENCINITAS CA
92024-4939
US

IV. Provider business mailing address

4403 MANCHESTER AVE SUITE 101
ENCINITAS CA
92024-4939
US

V. Phone/Fax

Practice location:
  • Phone: 760-436-6365
  • Fax: 760-436-5123
Mailing address:
  • Phone: 760-436-6365
  • Fax: 760-436-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADLEY ALLEN ELI
Title or Position: PRESIDENT
Credential: DMD
Phone: 760-436-4062