Provider Demographics
NPI:1508933730
Name:HARGRAVE, BRAD (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
Last Name:HARGRAVE
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 1:411 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2027
Mailing Address - Country:US
Mailing Address - Phone:618-498-6493
Mailing Address - Fax:618-498-6493
Practice Address - Street 1:411 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052
Practice Address - Country:US
Practice Address - Phone:618-498-6493
Practice Address - Fax:618-498-6493
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0268111223G0001X
IL0190268111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice