Provider Demographics
NPI:1710073127
Name:ORTH, BRAD T (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:T
Last Name:ORTH
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 1:3455 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-4500
Mailing Address - Country:US
Mailing Address - Phone:316-943-0247
Mailing Address - Fax:316-941-4194
Practice Address - Street 1:3455 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4500
Practice Address - Country:US
Practice Address - Phone:316-943-0247
Practice Address - Fax:316-941-4194
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
116-525OtherBCBS