Provider Demographics
NPI:1336450618
Name:YOUNG, BRADLEY JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JEROME
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-3046
Mailing Address - Country:US
Mailing Address - Phone:563-652-3438
Mailing Address - Fax:
Practice Address - Street 1:129 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-3046
Practice Address - Country:US
Practice Address - Phone:563-652-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice