Healthcare Provider Details

I. General information

NPI: 1841204617
Provider Name (Legal Business Name): BRADLEY F. MARINEAU D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12755 SW 2ND ST
BEAVERTON OR
97005-2767
US

IV. Provider business mailing address

12755 SW 2ND ST
BEAVERTON OR
97005-2767
US

V. Phone/Fax

Practice location:
  • Phone: 503-641-5303
  • Fax: 503-646-4193
Mailing address:
  • Phone: 503-641-5303
  • Fax: 503-646-4193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6567
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: