Provider Demographics
NPI:1003224148
Name:BRADLEY, ALIJAH (DDS)
Entity Type:Individual
Prefix:
First Name:ALIJAH
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 NE 10TH AVE APT 225
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5936
Mailing Address - Country:US
Mailing Address - Phone:734-904-4589
Mailing Address - Fax:
Practice Address - Street 1:4267 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-3305
Practice Address - Country:US
Practice Address - Phone:954-677-3202
Practice Address - Fax:954-677-3201
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 208451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice