Provider Demographics
NPI:1245438324
Name:WILTBANK, BRADLEY DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:WILTBANK
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 1:6836 CHELSEA RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-2803
Mailing Address - Country:US
Mailing Address - Phone:425-280-5252
Mailing Address - Fax:
Practice Address - Street 1:1313 DOLLEY MADISON BLVD
Practice Address - Street 2:SUITE #209
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3953
Practice Address - Country:US
Practice Address - Phone:703-356-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD89441223G0001X
VA04014142481223S0112X, 122300000X
WADE000112461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist