Provider Demographics
NPI:1134108970
Name:HARRIS, BRADLEY K (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:K
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10604 E 96TH ST
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9798
Mailing Address - Country:US
Mailing Address - Phone:317-845-8135
Mailing Address - Fax:317-845-8143
Practice Address - Street 1:10604 E 96TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9798
Practice Address - Country:US
Practice Address - Phone:317-845-8135
Practice Address - Fax:317-845-8143
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12010406A122300000X
IN12010406A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200384890AMedicaid