Healthcare Provider Details

I. General information

NPI: 1700512084
Provider Name (Legal Business Name): DENNIS EDWARD BRADTKE NA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 MISSION GORGE RD
SANTEE CA
92071-3027
US

IV. Provider business mailing address

10201 MISSION GORGE RD
SANTEE CA
92071-3027
US

V. Phone/Fax

Practice location:
  • Phone: 619-383-6868
  • Fax: 619-312-2661
Mailing address:
  • Phone: 619-383-6868
  • Fax: 619-312-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: