Basic Information
| Provider Information | |||||||||
| NPI: | 1225410590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLE | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9306 VANGUARD CT | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211178291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124142740 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 S DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176024509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172996371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DS040480 | PA | Y | Dental Providers | Dentist | General Practice |
No ID Information.