Provider Demographics
NPI:1205945425
Name:BRAVERMAN, NATHAN ALAN (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ALAN
Last Name:BRAVERMAN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 FIRST STREET
Mailing Address - Street 2:SUITE 350
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-5601
Mailing Address - Country:US
Mailing Address - Phone:847-433-1516
Mailing Address - Fax:847-433-1548
Practice Address - Street 1:1770 FIRST STREET
Practice Address - Street 2:SUITE 350
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-5601
Practice Address - Country:US
Practice Address - Phone:847-433-1516
Practice Address - Fax:847-433-1548
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190235441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH54823Medicare UPIN
IL206246Medicare ID - Type Unspecified