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General NPI Number Information
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NPI Number | 1396899878
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Entity Type | Organization
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Legal Business Name | BRADLEY W ROBERTS DMD PC
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4 PROFESSIONAL DRIVE
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City | ALTON
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State | IL
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Zip | 62002
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Country | US
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Telephone | 618-465-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 4 PROFESSIONAL DRIVE
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City | ALTON
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State | IL
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Zip | 62002
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Country | US
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Telephone | 618-465-9000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRADLEY WANE ROBERTS
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Credential | DMD
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Telephone | 618-465-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State | IL
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