Provider Demographics
NPI:1235240730
Name:BRADEL, MARK S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:BRADEL
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 1:5647 ELEVATOR RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8879
Mailing Address - Country:US
Mailing Address - Phone:815-623-2300
Mailing Address - Fax:815-623-6707
Practice Address - Street 1:5647 ELEVATOR RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8879
Practice Address - Country:US
Practice Address - Phone:815-623-2300
Practice Address - Fax:815-623-6707
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice