Healthcare Provider Details

I. General information

NPI: 1801262530
Provider Name (Legal Business Name): BRADLEY PAUL STORRS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6837 NORMANDY RD BLDG B ATTN: CHARLES BERNATOVITZ
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

69 LONDON DR
FORT BRAGG NC
28307-1913
US

V. Phone/Fax

Practice location:
  • Phone: 910-643-2196
  • Fax:
Mailing address:
  • Phone: 720-233-7368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2015020280
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: