Healthcare Provider Details

I. General information

NPI: 1790841765
Provider Name (Legal Business Name): BRADLEY VERGIEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 05/20/2010
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: 505-863-8700
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
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3565
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number145124-9921
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number759
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: