Provider Demographics
NPI:1497360457
Name:NORMAN, BRADLEY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:NORMAN
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-0428
Mailing Address - Country:US
Mailing Address - Phone:253-389-0526
Mailing Address - Fax:
Practice Address - Street 1:33421 WEBSTER RD E
Practice Address - Street 2:
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328-8685
Practice Address - Country:US
Practice Address - Phone:253-389-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE610856151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice