Provider Demographics
NPI:1407990286
Name:BRADLEY J KIRST DDS INC
Entity Type:Organization
Organization Name:BRADLEY J KIRST DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIRST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-288-2088
Mailing Address - Street 1:23838 VALENCIA BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355
Mailing Address - Country:US
Mailing Address - Phone:661-288-2088
Mailing Address - Fax:661-288-2218
Practice Address - Street 1:23838 VALENCIA BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355
Practice Address - Country:US
Practice Address - Phone:661-288-2088
Practice Address - Fax:661-288-2218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty