Provider Demographics
NPI:1841230638
Name:STUTLER, BRADLEY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:STUTLER
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 1:1460 N GREEN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-8117
Mailing Address - Country:US
Mailing Address - Phone:317-852-6620
Mailing Address - Fax:317-852-6680
Practice Address - Street 1:1460 N GREEN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-8117
Practice Address - Country:US
Practice Address - Phone:317-852-6620
Practice Address - Fax:317-852-6680
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1841230638332B00000X
IN12010504A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200437880Medicaid
IN202505233Medicare UPIN