Healthcare Provider Details

I. General information

NPI: 1578557823
Provider Name (Legal Business Name): BRAD LAMONT BATEMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 13TH ST SE
SALEM OR
97302-2506
US

IV. Provider business mailing address

1005 13TH ST SE
SALEM OR
97302-2506
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-7232
  • Fax: 503-364-9187
Mailing address:
  • Phone: 503-364-7232
  • Fax: 503-364-9187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6913
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number39599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: