Provider Demographics
NPI:1396843371
Name:MITCHELL, BRADLEY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:SCOTT
Last Name:MITCHELL
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 1:4200 W MEMORIAL RD
Mailing Address - Street 2:SUITE 809
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9350
Mailing Address - Country:US
Mailing Address - Phone:405-755-2670
Mailing Address - Fax:
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:SUITE 809
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-755-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6599122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1437110020Medicare PIN