Provider Demographics
NPI:1720473267
Name:BARTLEY, KADEEM
Entity Type:Individual
Prefix:
First Name:KADEEM
Middle Name:
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HOBBES LN APT A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1241
Mailing Address - Country:US
Mailing Address - Phone:860-751-2470
Mailing Address - Fax:860-751-2470
Practice Address - Street 1:728 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1719
Practice Address - Country:US
Practice Address - Phone:585-491-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059451-1122300000X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program