Healthcare Provider Details

I. General information

NPI: 1205948270
Provider Name (Legal Business Name): BRADLEY A ELI DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 W VISTA WAY STE 218
VISTA CA
92083-6029
US

IV. Provider business mailing address

2095 W VISTA WAY STE 218
VISTA CA
92083-6029
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberDS36308
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code125Q00000X
TaxonomyOral Medicine Dentistry
License NumberDS36308
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number36308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: