Provider Demographics
NPI:1700512084
Name:BRADTKE, DENNIS EDWARD (NA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:EDWARD
Last Name:BRADTKE
Suffix:
Gender:M
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 MISSION GORGE RD
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3027
Mailing Address - Country:US
Mailing Address - Phone:619-383-6868
Mailing Address - Fax:619-312-2661
Practice Address - Street 1:10201 MISSION GORGE RD
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3027
Practice Address - Country:US
Practice Address - Phone:619-383-6868
Practice Address - Fax:619-312-2661
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA