Provider Demographics
NPI:1295577799
Name:BROW, BRADLEY JOSEPH (DMD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOSEPH
Last Name:BROW
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 1:1448 WOODWARD AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2020
Mailing Address - Country:US
Mailing Address - Phone:906-235-3814
Mailing Address - Fax:
Practice Address - Street 1:9115 TELEGRAPH ROAD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-2365
Practice Address - Country:US
Practice Address - Phone:313-908-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016022631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice