Provider Demographics
NPI:1447240056
Name:BRADLEY, MICHAEL EDGAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDGAR
Last Name:BRADLEY
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 1:5424 REILLY RD
Mailing Address - Street 2:BLDG 260
Mailing Address - City:POPE AFB
Mailing Address - State:NC
Mailing Address - Zip Code:28308-2324
Mailing Address - Country:US
Mailing Address - Phone:910-394-2123
Mailing Address - Fax:
Practice Address - Street 1:5424 REILLY RD
Practice Address - Street 2:BLDG 260
Practice Address - City:POPE AFB
Practice Address - State:NC
Practice Address - Zip Code:28308-2324
Practice Address - Country:US
Practice Address - Phone:910-394-2123
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1050471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice