MEDICARE: BRADLEY A. ELI DENTAL CORPORATION

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	1223X2210X	Orofacial Pain Dentistry
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1427740794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY A. ELI DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	5830 OBERLIN DR STE 202
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3754
Country	:	US
Telephone Number	:	844-235-9881
Fax Number	:	760-436-5123

Provider Business Practice Location Address
First Line	:	5830 OBERLIN DR STE 202
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3754
Country	:	US
Telephone Number	:	844-235-9881
Fax Number	:	760-436-5123

Authorized Official
Title or Position	:	CEO
Name	:	DR. BRADLEY ALLEN ELI
Credential	:	DND
Telephone Number	:	844-235-9881

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	06/20/2023

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