Provider Demographics
NPI:1295906584
Name:BRADLEY DENTAL, LLC
Entity type:Organization
Organization Name:BRADLEY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KOUSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-929-0222
Mailing Address - Street 1:2034 N STATE ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4410
Mailing Address - Country:US
Mailing Address - Phone:815-929-0222
Mailing Address - Fax:
Practice Address - Street 1:2034 N STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4410
Practice Address - Country:US
Practice Address - Phone:815-929-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty