Provider Demographics
NPI:1023237559
Name:ORTHODONTIC ASSOCIATES, S.C.
Entity type:Organization
Organization Name:ORTHODONTIC ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-261-3560
Mailing Address - Street 1:1510 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4102
Mailing Address - Country:US
Mailing Address - Phone:920-261-3560
Mailing Address - Fax:920-261-3561
Practice Address - Street 1:1510 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4102
Practice Address - Country:US
Practice Address - Phone:920-261-3560
Practice Address - Fax:920-261-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5275-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========OtherORTHODONTICS