Provider Demographics
NPI:1427401827
Name:LERUD, BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:LERUD
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 1:323 N LEROUX ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4540
Mailing Address - Country:US
Mailing Address - Phone:928-774-1168
Mailing Address - Fax:
Practice Address - Street 1:323 N LEROUX ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4540
Practice Address - Country:US
Practice Address - Phone:928-774-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ95071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice