Provider Demographics
NPI:1720074479
Name:TINER, BRADFORD WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:WAYNE
Last Name:TINER
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 1:3013 E RENNER RD. STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082
Mailing Address - Country:US
Mailing Address - Phone:972-231-3013
Mailing Address - Fax:
Practice Address - Street 1:3013 E RENNER RD. STE 100
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082
Practice Address - Country:US
Practice Address - Phone:972-231-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0159211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice