MEDICARE: DR. BRADLEY R ROSS DMD

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	019-026275	IL
2	1223E0200X	Endodontics	DEN03064	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019-026275	OTHER	IL	DENTIST

General Provider Information

NPI Number	:	1679566418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY R ROSS DMD

Provider Business Mailing Address
First Line	:	31 KING CHARLES DR
Second Line	:
City	:	PORTSMOUTH
State	:	RI
Zip	:	02871-1365
Country	:	US
Telephone Number	:	401-293-5933
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 KING CHARLES DR
Second Line	:
City	:	PORTSMOUTH
State	:	RI
Zip	:	02871-1365
Country	:	US
Telephone Number	:	401-293-5933
Fax Number	:

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

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	02/02/2010

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