Healthcare Provider Details

I. General information

NPI: 1407326440
Provider Name (Legal Business Name): JANINE MARIE BRADLEY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 MACON AVE
CANON CITY CO
81212-3225
US

IV. Provider business mailing address

1001 S INDIAN BEND DR
PUEBLO WEST CO
81007-6158
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-0117
  • Fax:
Mailing address:
  • Phone: 719-276-0117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000906087
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: