Provider Demographics
NPI:1568580074
Name:ROBERTSON, BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:ROBERTSON
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 1:2957 W COLONY CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7201
Mailing Address - Country:US
Mailing Address - Phone:208-938-3520
Mailing Address - Fax:
Practice Address - Street 1:1212 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8646
Practice Address - Country:US
Practice Address - Phone:208-322-1747
Practice Address - Fax:208-322-1748
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID834079OtherUNITED CONCORDIA ID #