Provider Demographics
NPI:1619069614
Name:SKILLEN, BRADLEY K (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:K
Last Name:SKILLEN
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:PO BOX 207
Mailing Address - Street 2:1700 JAMES
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-0207
Mailing Address - Country:US
Mailing Address - Phone:316-788-3736
Mailing Address - Fax:316-788-4158
Practice Address - Street 1:1700 JAMES ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3543
Practice Address - Country:US
Practice Address - Phone:316-788-3736
Practice Address - Fax:316-788-4158
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
794415OtherUNITED CONCORDIA