=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790841765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY VERGIEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 US 491
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-863-8000
-----------------------------------------------------
Fax | 505-863-8700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 MILDA ST
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-879-9191
-----------------------------------------------------
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 | DD1926
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3565
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 145124-9921
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 759
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------