Provider Demographics
NPI:1912250135
Name:BRADLEY A PURCELL D.D.S. M.S. & RYAN M. MIZUMOTO D.M.D., M.S., INC
Entity Type:Organization
Organization Name:BRADLEY A PURCELL D.D.S. M.S. & RYAN M. MIZUMOTO D.M.D., M.S., INC
Other - Org Name:SPECTRUM DENTAL & PROSTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:614-885-4249
Mailing Address - Street 1:55 CAREN AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2515
Mailing Address - Country:US
Mailing Address - Phone:614-888-7012
Mailing Address - Fax:614-888-0284
Practice Address - Street 1:55 CAREN AVE STE 270
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2515
Practice Address - Country:US
Practice Address - Phone:614-888-7012
Practice Address - Fax:614-888-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI151741223P0700X
IL226551223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty