Healthcare Provider Details

I. General information

NPI: 1447399803
Provider Name (Legal Business Name): BRADLEY JEROME NELSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 E SAHARA AVE #2
LAS VEGAS NV
89104-3032
US

IV. Provider business mailing address

860 E SAHARA AVE #2
LAS VEGAS NV
89104-3032
US

V. Phone/Fax

Practice location:
  • Phone: 702-734-8376
  • Fax: 702-734-8520
Mailing address:
  • Phone: 702-734-8376
  • Fax: 702-734-8520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number690
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: