Provider Demographics
NPI:1346461696
Name:BRADLEY, THOMAS GERARD
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GERARD
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4102
Mailing Address - Country:US
Mailing Address - Phone:920-261-3560
Mailing Address - Fax:920-261-3561
Practice Address - Street 1:1510 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4102
Practice Address - Country:US
Practice Address - Phone:920-261-3560
Practice Address - Fax:920-261-3561
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5275-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics