Provider Demographics
NPI:1639244619
Name:ANGELL, BRADLEY G (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:ANGELL
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10412 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3120
Mailing Address - Country:US
Mailing Address - Phone:502-425-3350
Mailing Address - Fax:502-425-3789
Practice Address - Street 1:10412 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3120
Practice Address - Country:US
Practice Address - Phone:502-425-3350
Practice Address - Fax:502-425-3789
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1695639OtherUCCI
KY506626OtherUCCI