Provider Demographics
NPI:1205960796
Name:BRADLEY J. SMITH D.D.S. PC
Entity type:Organization
Organization Name:BRADLEY J. SMITH D.D.S. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-524-4880
Mailing Address - Street 1:238 NE TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5696
Mailing Address - Country:US
Mailing Address - Phone:816-524-4880
Mailing Address - Fax:816-524-2868
Practice Address - Street 1:238 NE TUDOR RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5696
Practice Address - Country:US
Practice Address - Phone:816-524-4880
Practice Address - Fax:816-524-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO960330Medicare UPIN
MO16669023Medicare UPIN