Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DD3526 | NM |
Y | 1223X0400X | Orthodontists | 8251 | AZ |
NPI | 1043595259 |
---|---|
Provider Name | Dr. Bradley R Smith |
First Address | Safford, AZ 85546-4053 |
Second Address | Safford, AZ 85546-4053 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2011 |
Last Update Date | 19/10/2011 |