Provider Demographics
NPI:1417448200
Name:MOSES, BRADLEY LEE (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:LEE
Last Name:MOSES
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 1:4835 HEARST ST APT 207
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-1192
Mailing Address - Country:US
Mailing Address - Phone:913-602-0519
Mailing Address - Fax:
Practice Address - Street 1:7030 YOUREE DR STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5109
Practice Address - Country:US
Practice Address - Phone:318-402-4604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice