Healthcare Provider Details

I. General information

NPI: 1770848129
Provider Name (Legal Business Name): BRADLEY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21635 RYAN RD
WARREN MI
48091-2788
US

IV. Provider business mailing address

21635 RYAN RD
WARREN MI
48091-2788
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-7540
  • Fax:
Mailing address:
  • Phone: 586-757-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2451596
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number15917
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15917
License Number StateMI

VIII. Authorized Official

Name: DANA HORSCH
Title or Position: MANAGER
Credential:
Phone: 586-757-7540