Provider Demographics
NPI:1770848129
Name:BRADLEY DENTAL
Entity type:Organization
Organization Name:BRADLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HORSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-757-7540
Mailing Address - Street 1:21635 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2788
Mailing Address - Country:US
Mailing Address - Phone:586-757-7540
Mailing Address - Fax:
Practice Address - Street 1:21635 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2788
Practice Address - Country:US
Practice Address - Phone:586-757-7540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI24515961223S0112X
MI1223X0400X
MI15917332BC3200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty