=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174148423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADY KEVIN SCHNEIDER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2020
-----------------------------------------------------
Last Update Date | 06/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44405 WOODWARD AVE # H23
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-858-3234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 541 HICKORY ST
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48381-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-660-5216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2951000813
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------