Provider Demographics
NPI:1467543595
Name:SUTTON, BRADLEY W (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:W
Last Name:SUTTON
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 1:475 YELLOWSTONE AVE
Mailing Address - Street 2:STE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-3500
Mailing Address - Fax:208-232-3505
Practice Address - Street 1:475 YELLOWSTONE AVE
Practice Address - Street 2:STE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-3500
Practice Address - Fax:208-232-3505
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
6P055OtherBLUE CROSS BLUE SHIELD OF