Provider Demographics
NPI:1578587630
Name:LACONI, BRADLEY PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PAUL
Last Name:LACONI
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 1:11 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46017-1057
Mailing Address - Country:US
Mailing Address - Phone:765-378-0271
Mailing Address - Fax:765-378-4364
Practice Address - Street 1:11 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:IN
Practice Address - Zip Code:46017-1057
Practice Address - Country:US
Practice Address - Phone:765-378-0271
Practice Address - Fax:765-378-4364
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120088021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice