Provider Demographics
NPI:1679966550
Name:PACKER, BRADLEY (DMD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:PACKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3152
Mailing Address - Country:US
Mailing Address - Phone:507-269-6620
Mailing Address - Fax:
Practice Address - Street 1:3506 LOCHWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2995
Practice Address - Country:US
Practice Address - Phone:970-377-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist