Provider Demographics
NPI:1407025521
Name:VIDEEN, BRADLEY LEE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:LEE
Last Name:VIDEEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BIRCH ST. N STE. # 106
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008
Mailing Address - Country:US
Mailing Address - Phone:763-689-3134
Mailing Address - Fax:763-689-6609
Practice Address - Street 1:140 BIRCH ST N STE 106
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1547
Practice Address - Country:US
Practice Address - Phone:763-689-3134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45-4079726OtherMEDICAL ASSISTANCE