Provider Demographics
NPI:1194212175
Name:PICO, BRADLEY JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOSEPH
Last Name:PICO
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 1:9836 E OSAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2113
Mailing Address - Country:US
Mailing Address - Phone:480-628-9134
Mailing Address - Fax:
Practice Address - Street 1:2500 S POWER RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6687
Practice Address - Country:US
Practice Address - Phone:480-290-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice