Provider Demographics
NPI:1720236128
Name:MITCHELL, BRADLEY W (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:W
Last Name:MITCHELL
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 1:413 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1358
Mailing Address - Country:US
Mailing Address - Phone:618-939-6128
Mailing Address - Fax:618-939-6128
Practice Address - Street 1:413 W 3RD ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1358
Practice Address - Country:US
Practice Address - Phone:618-939-6128
Practice Address - Fax:618-939-6128
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190158011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice