Healthcare Provider Details

I. General information

NPI: 1700994852
Provider Name (Legal Business Name): BRADLEY LYNN TOWNSEND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 N. EAGLE RD.
BOISE ID
83713
US

IV. Provider business mailing address

6019 N. EAGLE RD.
BOISE ID
83713
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2777
  • Fax: 208-377-3075
Mailing address:
  • Phone: 208-377-2777
  • Fax: 208-377-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5910
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number06580
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: