Healthcare Provider Details

I. General information

NPI: 1093237729
Provider Name (Legal Business Name): BRADLEY MICHEL HERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 11/18/2023
Certification Date: 11/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 83RD ST STE 215
PRAIRIE VILLAGE KS
66208-5120
US

IV. Provider business mailing address

17297 W 93RD PL
LENEXA KS
66219-2597
US

V. Phone/Fax

Practice location:
  • Phone: 913-381-5292
  • Fax:
Mailing address:
  • Phone: 913-485-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2020007084
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number61569
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: