Provider Demographics
NPI:1790841765
Name:VERGIEN, BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:VERGIEN
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 1:1600 MILDA ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6117
Mailing Address - Country:US
Mailing Address - Phone:505-879-9191
Mailing Address - Fax:
Practice Address - Street 1:1421 US 491
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-863-8000
Practice Address - Fax:505-863-8700
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1926122300000X
AZD3565122300000X
UT145124-9921122300000X
AK759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist