Healthcare Provider Details

I. General information

NPI: 1134248230
Provider Name (Legal Business Name): BRADLEY DAVID LEVALLEY D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 WHALERS WAY SUITE 300
FORT COLLINS CO
80525-7585
US

IV. Provider business mailing address

3744 S TIMBERLINE RD SUITE 101
FORT COLLINS CO
80525-4333
US

V. Phone/Fax

Practice location:
  • Phone: 970-229-1404
  • Fax: 970-229-1422
Mailing address:
  • Phone: 970-229-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7382
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: