Provider Demographics
NPI:1649242132
Name:THERIOT, BRAD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:THERIOT
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 1:711 W 38TH ST
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-454-1220
Mailing Address - Fax:
Practice Address - Street 1:2501 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE 6B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5281
Practice Address - Country:US
Practice Address - Phone:512-447-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
84G431Medicare ID - Type Unspecified
T16248Medicare UPIN