Healthcare Provider Details

I. General information

NPI: 1477581908
Provider Name (Legal Business Name): JON P BRADRICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 METROHEALTH DR MHMC-SURGERY/ORAL & MAX
CLEVELAND OH
44109-1900
US

IV. Provider business mailing address

2500 METROHEALTH DR MHMC-SURGERY/ORAL & MAX
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 216-778-4488
  • Fax:
Mailing address:
  • Phone: 216-778-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30018571
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberTX 19114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: