Provider Demographics
NPI:1407571136
Name:BRADLEY, AMANDA PAIGE (DMD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:PAIGE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 W CELTIC CIR # 1
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6431
Mailing Address - Country:US
Mailing Address - Phone:702-510-6683
Mailing Address - Fax:
Practice Address - Street 1:4641 E FRONTIER PLAZA DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-373-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK196841122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1733188Medicaid