Healthcare Provider Details

I. General information

NPI: 1316293145
Provider Name (Legal Business Name): BRADLEY R DANIEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W MULBERRY
PILOT KNOB MO
63663
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-546-1001
  • Fax: 573-546-1002
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2012024991
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: