Healthcare Provider Details

I. General information

NPI: 1194833897
Provider Name (Legal Business Name): BRADLEY JAMES VANCE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 TRAVIS ST
HOUSTON TX
77030-1312
US

IV. Provider business mailing address

6655 TRAVIS ST
HOUSTON TX
77030-1312
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-8220
  • Fax: 713-500-8210
Mailing address:
  • Phone: 713-500-8220
  • Fax: 713-500-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number18495
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: