Provider Demographics
NPI:1376573196
Name:DITSWORTH, BRADLEY ARTHUR (DMD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ARTHUR
Last Name:DITSWORTH
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 1:2458 E RUSSELL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2474
Mailing Address - Country:US
Mailing Address - Phone:702-798-6216
Mailing Address - Fax:702-798-6269
Practice Address - Street 1:2458 E RUSSELL RD
Practice Address - Street 2:SUITE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2474
Practice Address - Country:US
Practice Address - Phone:702-798-6216
Practice Address - Fax:702-798-6269
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist