=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366978082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLY JAMES MOURITSEN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2017
-----------------------------------------------------
Last Update Date | 10/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3467 PINE RIDGE RD STE 101
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34109-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-251-5045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3467 PINE RIDGE RD STE 101
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34109-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-251-5045
-----------------------------------------------------
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 | D1172
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10341065-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN25384
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------