Healthcare Provider Details

I. General information

NPI: 1417275165
Provider Name (Legal Business Name): BRADLEY VERGIEN DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 US 491
GALLUP NM
87301
US

IV. Provider business mailing address

1600 MILDA ST
GALLUP NM
87301-6117
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-8000
  • Fax:
Mailing address:
  • Phone: 505-879-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1926
License Number StateNM

VIII. Authorized Official

Name: DR. BRADLEY VERGIEN
Title or Position: OWNER
Credential:
Phone: 505-879-9191