Provider Demographics
NPI:1497853220
Name:MORLOCK, BRADLEY JAY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAY
Last Name:MORLOCK
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 1:3323 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4423
Mailing Address - Country:US
Mailing Address - Phone:208-743-1114
Mailing Address - Fax:208-743-0120
Practice Address - Street 1:3323 4TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4423
Practice Address - Country:US
Practice Address - Phone:208-743-1114
Practice Address - Fax:208-743-0120
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD2072PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD2072 PEOtherDENTAL LICENSE