=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912250135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRADLEY A PURCELL D.D.S. M.S. & RYAN M. MIZUMOTO D.M.D., M.S., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2012
-----------------------------------------------------
Last Update Date | 11/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 CAREN AVE STE 270
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-888-7012
-----------------------------------------------------
Fax | 614-888-0284
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 CAREN AVE STE 270
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-888-7012
-----------------------------------------------------
Fax | 614-888-0284
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | BRADLEY A PURCELL
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 614-885-4249
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 22655
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 15174
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------