MEDICARE: DR. BRADLEY RICHARD OLIVER 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	122300000X	Dentist	0401415365	VA
2	1223G0001X	General Practice Dentistry	0401415365	VA

General Provider Information

NPI Number	:	1992259998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY RICHARD OLIVER DDS

Provider Business Mailing Address
First Line	:	4572 FRANKLIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24014-5144
Country	:	US
Telephone Number	:	540-769-5020
Fax Number	:	540-769-5021

Provider Business Practice Location Address
First Line	:	4572 FRANKLIN RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24014-5144
Country	:	US
Telephone Number	:	540-769-5020
Fax Number	:	540-769-5021

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

Provider Enumeration Date	:	08/08/2016
Last Update Date	:	08/08/2016

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