Provider Demographics
NPI:1710911862
Name:GREGORY, BRADLEY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:A
Last Name:GREGORY
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 1:8543 INDIAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-8834
Mailing Address - Country:US
Mailing Address - Phone:419-425-0195
Mailing Address - Fax:419-423-4320
Practice Address - Street 1:1816 CHAPEL DR
Practice Address - Street 2:SUITE H
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-1331
Practice Address - Country:US
Practice Address - Phone:419-423-4651
Practice Address - Fax:419-423-4320
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH215531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2470302Medicaid
OHGR4108734Medicare ID - Type Unspecified
OHU95606Medicare UPIN