Provider Demographics
NPI:1093804858
Name:TALLY, JAMES BRAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRAD
Last Name:TALLY
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 1:13650 ROE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-3757
Mailing Address - Country:US
Mailing Address - Phone:913-491-5040
Mailing Address - Fax:
Practice Address - Street 1:13650 ROE BLVD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66224-3757
Practice Address - Country:US
Practice Address - Phone:913-491-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice