Provider Demographics
NPI:1912370560
Name:HULL, BRADLY KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLY
Middle Name:KEITH
Last Name:HULL
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 1:4304 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8815
Mailing Address - Country:US
Mailing Address - Phone:208-818-3733
Mailing Address - Fax:
Practice Address - Street 1:313 N SPOKANE ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9513
Practice Address - Country:US
Practice Address - Phone:208-773-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-46881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice