=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194924969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADNER J LAWRENCE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12610 WEST SILVERBELL RD
-----------------------------------------------------
City | MARANA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-616-4562
-----------------------------------------------------
Fax | 510-682-3548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12325 E SUTTER MILL ST
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D4597
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------