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General NPI Number Information
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NPI Number | 1982076097
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY BY DESIGN
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Dates
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Enumeration Date | 10/28/2015
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Last Update Date | 10/28/2015
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Provider Practice Location Address
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Address Line | 1848 HOPE AVE SUITE 2
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City | KINGMAN
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State | AZ
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Zip | 86401-4190
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Country | US
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Telephone | 928-753-5200
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Fax | 928-753-5205
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Provider Business Mailing Address
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Address Line | 1848 HOPE AVE SUITE 2
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City | KINGMAN
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State | AZ
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Zip | 86401-4190
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Country | US
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Telephone | 928-753-5200
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Fax | 928-753-5205
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Authorized Official
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Title or Position | OWNER / DENTIST
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Name | DR. KELLY BRADLEY
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Credential | DMD
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Telephone | 928-897-9946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7614
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License Number State | AZ
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