Provider Demographics
NPI:1124002332
Name:O'BRIEN, BRADFORD PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:PAUL
Last Name:O'BRIEN
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 1:321 9TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-1464
Mailing Address - Country:US
Mailing Address - Phone:509-548-5415
Mailing Address - Fax:509-548-2434
Practice Address - Street 1:321 9TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-1464
Practice Address - Country:US
Practice Address - Phone:509-548-5415
Practice Address - Fax:509-548-2434
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000070801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036371Medicaid
VA57080OtherWDS PROVIDER NUMBER
WALABOR AND INDUSTRIESOtherL&I