MEDICARE: DR. BRADLEY FULTON KENDZIOR D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS030660L	PA

General Provider Information

NPI Number	:	1174745046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY FULTON KENDZIOR D.D.S., M.S.

Provider Business Mailing Address
First Line	:	2119 ALLEGHENY BLVD.
Second Line	:	P.O. BOX 428
City	:	RENO
State	:	PA
Zip	:	16343-0428
Country	:	US
Telephone Number	:	814-676-5690
Fax Number	:	814-677-4120

Provider Business Practice Location Address
First Line	:	2119 ALLEGHENY BLVD.
Second Line	:
City	:	RENO
State	:	PA
Zip	:	16343-0428
Country	:	US
Telephone Number	:	814-676-5690
Fax Number	:	814-677-4120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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