Provider Demographics
NPI:1497074025
Name:ROBERTS, BRADLEY WANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WANE
Last Name:ROBERTS
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 1:4 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5067
Mailing Address - Country:US
Mailing Address - Phone:618-465-9000
Mailing Address - Fax:
Practice Address - Street 1:4 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5067
Practice Address - Country:US
Practice Address - Phone:618-465-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190197691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL757170Medicare PIN