Provider Demographics
NPI:1205141678
Name:BRADY, JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BRADY
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 1:515 7TH AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4949
Mailing Address - Country:US
Mailing Address - Phone:907-452-8296
Mailing Address - Fax:907-452-8298
Practice Address - Street 1:515 7TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4949
Practice Address - Country:US
Practice Address - Phone:907-452-8296
Practice Address - Fax:907-452-8298
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist