Provider Demographics
NPI:1841204617
Name:MARINEAU, BRADLEY F (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:F
Last Name:MARINEAU
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 1:12755 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2767
Mailing Address - Country:US
Mailing Address - Phone:503-641-5303
Mailing Address - Fax:503-646-4193
Practice Address - Street 1:12755 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2767
Practice Address - Country:US
Practice Address - Phone:503-641-5303
Practice Address - Fax:503-646-4193
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6567122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist