=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710911862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY A GREGORY D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1816 CHAPEL DR SUITE H
-----------------------------------------------------
City | FINDLAY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45840-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-423-4651
-----------------------------------------------------
Fax | 419-423-4320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8543 INDIAN LAKE DR
-----------------------------------------------------
City | FINDLAY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45840-8834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-425-0195
-----------------------------------------------------
Fax | 419-423-4320
-----------------------------------------------------
=====================================================
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 | 21553
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------