Provider Demographics
NPI:1578884094
Name:SEAGO, BRADLEY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:SEAGO
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 1:2333 N 6TH ST
Mailing Address - Street 2:MEDICAL EDUCATION
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2001
Mailing Address - Country:US
Mailing Address - Phone:970-298-7821
Mailing Address - Fax:970-298-1726
Practice Address - Street 1:2333 N 6TH ST
Practice Address - Street 2:MEDICAL EDUCATION
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2001
Practice Address - Country:US
Practice Address - Phone:970-298-7821
Practice Address - Fax:970-298-1726
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68003340Medicaid