Provider Demographics
NPI:1700930096
Name:BARNES, BRADLEY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:BARNES
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 1:13775 BENJAMIN CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5143
Mailing Address - Country:US
Mailing Address - Phone:309-827-5301
Mailing Address - Fax:309-452-2711
Practice Address - Street 1:211 LANDMARK DR
Practice Address - Street 2:SUITE E-3
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2160
Practice Address - Country:US
Practice Address - Phone:309-454-7337
Practice Address - Fax:309-452-2711
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice