MEDICARE: DR. BRADLEY PAUL LACONI DDS

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	1223G0001X	General Practice Dentistry	12008802	IN

General Provider Information

NPI Number	:	1578587630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY PAUL LACONI DDS

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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