=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205990314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY PITTMAN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 04/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 E 2ND ST
-----------------------------------------------------
City | DEFIANCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43512-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-783-6993
-----------------------------------------------------
Fax | 419-783-6992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 E 2ND ST
-----------------------------------------------------
City | DEFIANCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43512-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-783-6993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 30-022474
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------