Healthcare Provider Details

I. General information

NPI: 1073357752
Provider Name (Legal Business Name): ISABEL ANTOINETTE BRAVO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E 84TH DR STE 106
MERRILLVILLE IN
46410-6454
US

IV. Provider business mailing address

192 WEXFORD RD
VALPARAISO IN
46385-8047
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-2309
  • Fax:
Mailing address:
  • Phone: 219-477-8384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12014466A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: