Healthcare Provider Details

I. General information

NPI: 1427029503
Provider Name (Legal Business Name): BROOKS BRADLEY HORAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SE 133RD AVE
PORTLAND OR
97233-1809
US

IV. Provider business mailing address

405 SE 133RD AVE
PORTLAND OR
97233-1809
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-7188
  • Fax:
Mailing address:
  • Phone: 503-255-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9471
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD9544
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: