Provider Demographics
NPI:1437357282
Name:LAIRD, BRADLEY S (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:LAIRD
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 1:2805 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3305
Mailing Address - Country:US
Mailing Address - Phone:417-782-3636
Mailing Address - Fax:417-206-7844
Practice Address - Street 1:2805 E 29TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3305
Practice Address - Country:US
Practice Address - Phone:417-782-3636
Practice Address - Fax:417-206-7844
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070126551223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics