Provider Demographics
NPI:1225410590
Name:BRADLE, MARK (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRADLE
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 1:9306 VANGUARD CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-8291
Mailing Address - Country:US
Mailing Address - Phone:912-414-2740
Mailing Address - Fax:
Practice Address - Street 1:625 S DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4509
Practice Address - Country:US
Practice Address - Phone:717-299-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0404801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice