Provider Demographics
NPI:1265452577
Name:MOSENG, BRADLEY DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DEAN
Last Name:MOSENG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 LEGION DR
Mailing Address - Street 2:#1
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 LEGION DR
Practice Address - Street 2:#1
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1722
Practice Address - Country:US
Practice Address - Phone:329-269-7135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2209111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT70803Medicare UPIN