Healthcare Provider Details

I. General information

NPI: 1750570487
Provider Name (Legal Business Name): BRADLEY NIRENBLATT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 ELMS PLANTATION BLVD SUITE 102
NORTH CHARLESTON SC
29406-7101
US

IV. Provider business mailing address

2680 ELMS PLANTATION BLVD SUITE 102
NORTH CHARLESTON SC
29406-7101
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-1060
  • Fax: 843-863-9735
Mailing address:
  • Phone: 843-572-1060
  • Fax: 843-863-9735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0400
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: