Provider Demographics
NPI:1417573049
Name:BRADLEY, KRISTIN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:M
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:PO BOX 1250
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-1250
Mailing Address - Country:US
Mailing Address - Phone:802-295-7573
Mailing Address - Fax:
Practice Address - Street 1:70 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7061
Practice Address - Country:US
Practice Address - Phone:978-793-2835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT016.01339821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program