MEDICARE: BRADLEY ARTHUR DITSWORTH D.M.D.

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	122300000X	Dentist	2489	NV

General Provider Information

NPI Number	:	1376573196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY ARTHUR DITSWORTH D.M.D.

Provider Business Mailing Address
First Line	:	2458 E RUSSELL RD
Second Line	:	SUITE A
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-2474
Country	:	US
Telephone Number	:	702-798-6216
Fax Number	:	702-798-6269

Provider Business Practice Location Address
First Line	:	2458 E RUSSELL RD
Second Line	:	SUITE A
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-2474
Country	:	US
Telephone Number	:	702-798-6216
Fax Number	:	702-798-6269

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	07/08/2007

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