Provider Demographics
NPI:1568661387
Name:SMITH, BRADLEY MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MICHAEL
Last Name:SMITH
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 1:8700 MARBACH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-2345
Mailing Address - Country:US
Mailing Address - Phone:210-675-7000
Mailing Address - Fax:210-568-4774
Practice Address - Street 1:8700 MARBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245
Practice Address - Country:US
Practice Address - Phone:970-214-8735
Practice Address - Fax:210-568-4774
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9088122300000X
TX25764122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25764OtherTEXAS LICENSE
CO9088OtherSTATE LICENSE