Provider Demographics
NPI:1487004925
Name:NELSON, BRADLEY G (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:NELSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 W VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8104
Mailing Address - Country:US
Mailing Address - Phone:479-715-6845
Mailing Address - Fax:479-715-6851
Practice Address - Street 1:5215 W VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8104
Practice Address - Country:US
Practice Address - Phone:479-715-6845
Practice Address - Fax:479-715-6851
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR40891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221300608Medicaid