Provider Demographics
NPI:1821152729
Name:WEISS, BRADLEY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALAN
Last Name:WEISS
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 1:636 CHURCH ST
Mailing Address - Street 2:SUITE 200 W
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:847-864-0082
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 200 W
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-864-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist