MEDICARE: BRADLEY P LACONI DDS PC

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	261QD0000X	Dental Clinic/Center	12008802A	IN

General Provider Information

NPI Number	:	1285020560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY P LACONI DDS PC

Provider Business Mailing Address
First Line	:	11 SKYVIEW DR
Second Line	:
City	:	CHESTERFIELD
State	:	IN
Zip	:	46017-1057
Country	:	US
Telephone Number	:	765-378-0271
Fax Number	:	765-378-4364

Provider Business Practice Location Address
First Line	:	11 SKYVIEW DR
Second Line	:
City	:	CHESTERFIELD
State	:	IN
Zip	:	46017-1057
Country	:	US
Telephone Number	:	765-378-0271
Fax Number	:	765-378-4364

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRADLEY P LACONI
Credential	:	DDS
Telephone Number	:	765-378-0271

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	04/13/2015

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