Provider Demographics
NPI:1568570059
Name:VAN MIERLO, BRADLEY LELAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:LELAND
Last Name:VAN MIERLO
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 1:1459 HUMBOLDT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928
Mailing Address - Country:US
Mailing Address - Phone:530-899-7804
Mailing Address - Fax:530-899-1246
Practice Address - Street 1:1459 HUMBOLDT RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928
Practice Address - Country:US
Practice Address - Phone:530-899-7804
Practice Address - Fax:530-899-1246
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26138122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist