Provider Demographics
NPI:1639387863
Name:SMITH, BRADLEY M
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HARDING WAY W
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-1611
Mailing Address - Country:US
Mailing Address - Phone:419-468-5242
Mailing Address - Fax:419-468-1260
Practice Address - Street 1:401 HARDING WAY W
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-1611
Practice Address - Country:US
Practice Address - Phone:419-468-5242
Practice Address - Fax:419-468-1260
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-019484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist