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General NPI Number Information
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NPI Number | 1417275165
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Entity Type | Organization
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Legal Business Name | BRADLEY VERGIEN DDS, LLC
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Dates
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Enumeration Date | 05/05/2010
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Last Update Date | 05/05/2010
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Provider Practice Location Address
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Address Line | 1421 US 491
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City | GALLUP
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State | NM
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Zip | 87301
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Country | US
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Telephone | 505-863-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 1600 MILDA ST
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City | GALLUP
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State | NM
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Zip | 87301-6117
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Country | US
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Telephone | 505-879-9191
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRADLEY VERGIEN
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Credential |
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Telephone | 505-879-9191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD1926
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License Number State | NM
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