Provider Demographics
NPI:1194842492
Name:KINCHELOE, BRADLEY B (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:B
Last Name:KINCHELOE
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 1:2625 WILDHORSE TRL
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2232
Mailing Address - Country:US
Mailing Address - Phone:307-638-6544
Mailing Address - Fax:
Practice Address - Street 1:6244 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3432
Practice Address - Country:US
Practice Address - Phone:307-638-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice