Provider Demographics
NPI:1205948270
Name:ELI, BRADLEY A (DMD, MS)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:ELI
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 MANCHESTER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4939
Mailing Address - Country:US
Mailing Address - Phone:760-436-6365
Mailing Address - Fax:760-436-5123
Practice Address - Street 1:4403 MANCHESTER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4939
Practice Address - Country:US
Practice Address - Phone:760-436-6365
Practice Address - Fax:760-436-5123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADS363081223S0112X, 1223X2210X, 208VP0000X
CA36308174400000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223X2210XDental ProvidersDentistOrofacial Pain
No174400000XOther Service ProvidersSpecialist
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD36308Medicare PIN
CA1260410001Medicare NSC
CAT72281Medicare UPIN